Delirium

[Also see  Delirium (Hospital Aquired) ]
Case Discussion
A 79-yo woman with mild dementia is 2 days post-op for an elective right total hip arthroplasty. The nurses note that she was trying to get out of bed and screamed at them when they put her back to bed. When you see her, she is somnolent but arousable. You ask her where she is, but she just picks at the sheets and speaks nonsensically.

The appropriate next step is:

A. Order a chest x-ray.
B. Order a CT head with contrast.
C. Order EEG.
D. Do no further testing; this is predictable progression of dementia.
E. Review her outpatient medications.

 
Diagnostic Criteria for Delirium
  • Acute disturbance of cognition (inattention: can’t focus, shift, or sustain attention)
  • KEY: Rapid onset (hours to days), fluctuation
  • Tactile or visual delusions common (auditory hallucinations rare)
Causes of Delirium
D  Drugs (toxicity and withdrawal)
 Electrolyte disturbance
L   Lack of drugs, liver disease
 Infection
R  Reduced sensory input
 Intracranial
U  Urinary retention/fecal impaction
M Myocardial/metabolic/pulmonary
Risk Factors for Delirium
  • Use of restraints
  • Four or more medicines in 24 hours
  • Use of indwelling urinary catheter
  • History of dementia, stroke, or Parkinson’s disease
Is Neuroimaging Always Needed?
  • Neuroimaging unnecessary if:
    • Clinical evaluation discloses an obvious treatable medical illness or problem.
    • No evidence of trauma or new focal neurologic signs.
    • Patient is arousable and able to follow simple commands
The Yale Delirium Prevention Program
Risk factors Intervention
Cognitive impairment Reality orientation
Therapeutic activities
Sleep deprivation Non-pharmacologic sleep protocol
Immobilization Early mobilization
Vision impairment Vision aids
Hearing impairment Amplifying devices
Dehydration Early recognition and volume repletion
 
Impact of Delirium Prevention
  • Reduced number of delirium episodes
  • Reduced total days of delirium
  • Did not reduce severity of delirium or risk of recurrence