Delirium
In medicine, delirium is a "disorder characterized by confusion; inattentiveness; disorientation; illusions; hallucinations; agitation; and in some instances autonomic nervous system overactivity )."[1][2]
According to the Diagnostic and Statistical Manual of Mental Disorders, delirium is "reduced ability to think or concentrate, restlessness, anxiety, irritability, drowsiness, hypersensitivity to stimuli, nightmares."[3]
Subsyndromal delirium
Subsyndromal delirium may cause morbidity among hospitalized individuals.[3]
Diagnosis
The confusion assessment method (CAM), which is an algorithm with four criteria based on the Diagnostic and Statistical Manual of Mental Disorders can help diagnose when the first two criteria are present and either the third or fourth criteria is present:[4]
- acute onset and fluctuating course
- inattention
- disorganized thinking
- altered level of consciousness
The Mini-mental state examination (MMSE) can also help and can be found in the appendix of its original publication.[5]
Specific disorders such as substance withdrawal syndrome, intoxication, Wernicke encephalopathy, and osmotic demyelination syndrome (central pontine myelinolysis) should be excluded.
Treatment
Antipsychotic agents, such as haloperidol less than 3.0 mg per day, can improve delirium.[6]
Cholinesterase inhibitors like donepezil do not clearly help, but they have not been well studied.[7]
Benzodiazepams may worsen delirium.[8]
Prevention
Who is at risk?
The strongest risk factors for developing delirium are impaired cognition and psychotropic drug use.[9]
A clinical prediction rule by Inouye et al for hospitalized geriatric patients assigned one point to each of the following:[10]
- vision impairment
- severe illness as defined by APACHE II score of 17 or more
- cognitive impairment. Score of 23 or less on the Mini-Mental State Examination
- high blood urea nitrogen/creatinine ratio of 18 or more
The rates of delirium were:[10]
- 0 points 3%
- 1-2 points 16%
- 3-4 points 32%
Interventions
"Proactive geriatric consultation may reduce delirium incidence and severity...prophylactic low dose haloperidol may reduce severity and duration of delirium episodes according to a systematic review by the Cochrane Collaboration."[11]
In a randomized controlled trial of 430 geriatric patients undergoing hip surgery (about half were for hip fracture) and at least one point on the Inouye prediction rule (see above), haloperidol 1.5 mg per day was started on admission and continued until 3 days after surgery reduced the severity and duration of delirium.[12] The incidence of delirium was insignificantly reduced from 15.1% and 16.5% to 15.1%. However, for secondary outcomes, the duration of delirium was reduced by 6 days and the duration of hospitalization was significantly reduced by 5 days. No adverse effects occurred. Curiously, the study suggests that patients were already in the hospital for two weeks when they were enrolled into the study. Patients in both the treatment and control groups received geriatric consultation.
References
- ↑ Anonymous (2024), Delirium (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Breitbart, William; Yesne Alici (2008-12-24). "Agitation and Delirium at the End of Life: "We Couldn't Manage Him"". JAMA 300 (24): 2898-2910. DOI:10.1001/jama.2008.885. Retrieved on 2009-01-07. Research Blogging.
- ↑ 3.0 3.1 Cole M, McCusker J, Dendukuri N, Han L (June 2003). "The prognostic significance of subsyndromal delirium in elderly medical inpatients". J Am Geriatr Soc 51 (6): 754–60. PMID 12757560. [e]
- ↑ Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI (December 1990). "Clarifying confusion: the confusion assessment method. A new method for detection of delirium". Ann. Intern. Med. 113 (12): 941–8. PMID 2240918. [e]
- ↑ Folstein MF, Folstein SE, McHugh PR (1975). ""Mini-mental state". A practical method for grading the cognitive state of patients for the clinician". Journal of psychiatric research 12 (3): 189-98. DOI:10.1016/0022-3956(75)90026-6. PMID 1202204. Research Blogging.
- ↑ Lonergan E, Britton AM, Luxenberg J, Wyller T (2007). "Antipsychotics for delirium". Cochrane Database Syst Rev (2): CD005594. DOI:10.1002/14651858.CD005594.pub2. PMID 17443602. Research Blogging.
- ↑ Overshott R, Karim S, Burns A (2008). "Cholinesterase inhibitors for delirium". Cochrane Database Syst Rev (1): CD005317. DOI:10.1002/14651858.CD005317.pub2. PMID 18254077. Research Blogging.
- ↑ Breitbart W, Marotta R, Platt MM, et al (February 1996). "A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients". Am J Psychiatry 153 (2): 231–7. PMID 8561204. [e]
- ↑ Dasgupta M, Dumbrell AC (October 2006). "Preoperative risk assessment for delirium after noncardiac surgery: a systematic review". J Am Geriatr Soc 54 (10): 1578–89. DOI:10.1111/j.1532-5415.2006.00893.x. PMID 17038078. Research Blogging.
- ↑ 10.0 10.1 Inouye SK, Viscoli CM, Horwitz RI, Hurst LD, Tinetti ME (September 1993). "A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics". Ann. Intern. Med. 119 (6): 474–81. PMID 8357112. [e]
- ↑ Siddiqi N, Stockdale R, Britton AM, Holmes J (2007). "Interventions for preventing delirium in hospitalised patients". Cochrane Database Syst Rev (2): CD005563. DOI:10.1002/14651858.CD005563.pub2. PMID 17443600. Research Blogging.
- ↑ Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al (October 2005). "Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study". J Am Geriatr Soc 53 (10): 1658–66. DOI:10.1111/j.1532-5415.2005.53503.x. PMID 16181163. Research Blogging.