Organic disorders I: delirium

M. Kopeček

Delirium = qualitative disturbances of consciousness

Patient is alert (vigilant) but his/her consciousness is clouded, non-clear,

non-lucid.

DSM5 diagnostic criteria

A. Disturbance in attentionB. The disturbance develops over a short period of time (usually

hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.

C. An additional disturbance in cognition (e.g., memory deficit, disorientation or perception).

D. The disturbances in Criteria A and C are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.

E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies.

A. disturbance in attention

reduced ability to direct, focus,

sustain, and shift attention and

awareness (reduced orientation

to the environment).

serial 7s

• I will ask you to count by subtracting seven from 100, and then, keep subtracting seven from your answer until I tell you to stop

93...85...79...72...65

patology: 2 and more failures

point: 1.…0..…0....1..…1

cube copying

“Copy this drawing as accurately as you can, in the space below”.

B. an additional disturbance in cognition

(e.g., memory deficit, disorientation, language, visuospatial ability, or

perception)

memory deficit

I will tell you three words that you will have to remember now and later on. Listen carefully. When I am through, tell me as many words as you can remember.

• FACE

• VELVET

• DAISY

clock test

“Draw a clock. Put in all the numbers and set the time to 10 past 11”.

clock test - evaluation

1 point – all numbers

1 point – correct order and placed in the

approx. quadrants on the clock face

1 point – correct place of the hour hand

1 point – correct place of the minute hand

--------------------------------------------

4 points = norm

3 points – abnormal result

clock test

memory disturbaces

• “I read some words to you earlier, which I asked you to remember. Tell me as many of those words as you can remember.”

disorientation

• What is the day today ?

• Tell me the months?

• Tell me year ?

• Where we are ?

• Why we are here?

i.e. Sunday instead Tuesday

In kitchen, you have a white coute.

There are no cookies.

1986

autum

Psychomotor disturbances (ICD10)

1) fluctuating between hypo and

hyperactivity

2) slowing of reaction time

3) brady or tachylalia

4) prolongation of startle reflex

Disturbances of sleep and sleep-wake cycle (ICD10)

1) insomnia, inversion of sleep cycle

2) progression of delirum at night

(SUNDOWN sy)

3) uneasy sleep with horrible dreaming

The disturbance develops over a short period of time (usually hours to a few days),

represents a change from baseline attention and awareness, and tends to fluctuate in

severity during the course of a day.

clinical symptoms

psychomotor tempo:

decrease or increase

response to questions:

slow, incoherent

clinical symptoms

disturbances of perceptions:

frequent visual and tactile hallucinations/illusions

thought disorder:

non-systematic delusions

clinical symptoms

judgement impairment:

1. Will a stone float on water ?

2. Are there fish in the sea ?

3. Does one pound weigh more than two?

4. Can you use a hammer to pound a nail?

clinical symptoms

emotions:

fluctuating – anxiety, fear, sedation, irritability,euforia, suprise

clinical symptoms

Increased sugestibility:

Pt is able to read from white paper/wall.

clinical symptoms

description: puzzled, confused, perplex, disorganised,

disoriented, agitated

description of behavior:He is not able to find his room….he urinate into thecorner….she put bed sheet to the toilet ….she unscrew all stopcock of central heating…she did not sleep, because she saw shining circles …he saw bugs in the blanket. We did not seenothing…

type of delirium symptoms

hyperactive

agitation, hypervigilance, hallucinations and delusions

hypoactive

lethargy, sedation, latention to response, low spontaneity, hypomimia

mixed mix of above

!!!

etiology a ddg.

intracranial- tumor, inflammations, edema, ischemia,

bleeding, trauma, epi-paroxysmus….

extracranial- toxic substances, alcohol- shock (cardial, septic, postsurgery)- hypo/hyperglykemia- other metab. disord. (hepatic, renal,….)

clinical subtype

F 05.0 delirium, not superimposed on dementia

F 05.1 delirium, superimposed on dementia

F 1X.03 acute intoxication with delirium

F 10.4 withdrawal with delirium

F10.3 alcohol withdrawal state

at least 3 symptoms after sudden reduction or stop of alcohol consumption

• tremor of tounge, eyelids, hands• sweating• nausea or vomitus• tachycardia or hypertension• headache• insomnia• malaise or faint• acustic, visual or tactile hallucinations/illusions

F10.3 „predelirant state“ that could be complicated with deliriumF10.40 withdrawal state with delirium without convulsionsF10.41 withdrawal state with delirium with convulsions

assessment

history

physical examination

mental state examination

biochemic assay, ECG

…more

therapy of delirium

1. causal tx 2. symptomatic tx (pain, fever, BP..)3. tx of agitation4. transfer to intens. care unit5. arrangement of environment (clock, light,

informations)

causal tx

infection ……….antibiotics

dehydratation….rehydratations

corections of metab.dist.(pH,glyk., urea..)

intoxication……detoxification, antidots

withdrawal state…clomethiazole

tx of agitation

induce appropriate sedation • assure patients safety • protection of exhaustion • improve cooperation during diagnostic process

delirium tremens……diazepam or clomethiazole

non-alcoholic delirium….antipsychoticsdelirium without dementia…haloperidoledelirium superimposed on dementia….tiapridale, buronile, risperidone/quetiapine

haloperidol in non-alcoh. delirium

• first option APfirst option AP

• without anticholinergic and hypotensive side eff.without anticholinergic and hypotensive side eff.

• i.v., i.m., p.o. applicationi.v., i.m., p.o. application

• plasma C max. i.v. in 5-20 minut plasma C max. i.v. in 5-20 minut

• plasma C max. p.o. in 4-6 hoursplasma C max. p.o. in 4-6 hours

• recommended dosis 1-2 mg/ 2-4 hoursrecommended dosis 1-2 mg/ 2-4 hours

antipsychotics in non-alcoh. delirium (gerontopopulation)

TIAPRIDETIAPRIDE

- night deliria – night dose 100 – 200 mg. night deliria – night dose 100 – 200 mg.

- deliria during a day up to 800-1200 mg deliria during a day up to 800-1200 mg

MELPERONE MELPERONE

- night deliria – night dose 25-100 mgnight deliria – night dose 25-100 mg

- deliria during a day up to 200-300 mg deliria during a day up to 200-300 mg

2nd generation antipsychotics

RISPERIDONE RISPERIDONE - one night dos. 0,5-1 mg- one night dos. 0,5-1 mg- rarely more than 2 mg per die - rarely more than 2 mg per die

OLANZAPINEOLANZAPINE- 2,5 – 5 mg in one dosis, rarely 10 mg/die- 2,5 – 5 mg in one dosis, rarely 10 mg/die

risk of increased mortality induced by risperidone risk of increased mortality induced by risperidone and olanzapine (NNH = 83, 10-12 week)and olanzapine (NNH = 83, 10-12 week)

QUETIAPINEQUETIAPINE- most safe 2nd generation antipsychotics- most safe 2nd generation antipsychotics

benzodiazepines

• first option in alcohol delirium or deliria after BZD first option in alcohol delirium or deliria after BZD

withdrawalwithdrawal

• CAVE !!! induction of paradox excitationsCAVE !!! induction of paradox excitations

• in case of lack of antipsychotics effects in case of lack of antipsychotics effects

combination with clonazepamecombination with clonazepame

clomethiazole

• inicialy 2-3 capsules and every 4 h up to inicialy 2-3 capsules and every 4 h up to sedation. Max. dosis 16 capsules/d. sedation. Max. dosis 16 capsules/d.

• Dont mix with BZD (depression of respiration)

• Cave ! No abrupt withdrawal

alcohol withdrawal state with delirium

• supplementation of thiamine supplementation of thiamine

• minerals (magnesium and kalium) minerals (magnesium and kalium)

• glucose and fluids glucose and fluids

• clomethiazole or diazepameclomethiazole or diazepame

supportive medications

• nootropics to improve cerebral metabolism and vigility sustainment during a day (i.e. piracetamole) – hypoactive delirium

• vitamins B a C

delirious patient with non-curable malignancy: • opiate analgetics• combos: antipsychotic, BZD and hydromorfine

case of 47-y.o. female

She was anxious and agitated. She wrote

confused e-mails. She did not sleep at night,

crying, say over again and again „I am back

at hotel“.

Montreal Cognitive Assessment

total score 10/30

4th day of Augmentin 1g 1-0-1

total score 22/30

2nd case

40-y.o. mason has been admited to ICU after surgery for perforation of gastric ulcer. 3rd postsurgery day was transfer to standard ward – quite, cooperative. 4th day – fever, sweating, 5th day shaking hands and nausea, 6th day tachycardia and insomnia, 7th day – confused, agitated, with visual hallucinations

What do you do with this patient ?

2nd case - therapy

1. inf 500 ml G5%+B1, B6, C+diazepam+KCl2. inf. FR+MgSO410%+KCl+diazepam+novalgin3. infuze FR+diazepam4. inf. like 15. inf. like 26. inf. like 3 Vasocardin 50 mg tbl. ½-0- ½Omeprazol 20 mg tbl. 1-0-1Epi: Epanutine 1 amp. in 10 ml FS slowly i.v.vomitus: Torecan 1 amp. i.m.BP over 150/100: Tensiomine 12,5 mg tbl.