Delirium Presentation Web
Delirium Presentation Web
Delirium Presentation Web
Delirium
An acute medical condition Common in UK critical care patients Serious adverse outcomes Bedside diagnosis May be first sign of a new infection Pathological not psychological
Delirium
Disturbance of consciousness Acute change in mental status Fluctuating course worse at night Develops over short time, hours to days Impaired attention Disorganised thinking
118 ITU medical patients over 65: 31% on admission. 70% during hospitalisation
McNicoll J AM Geriatri Soc. 2003;51(5):591
Pathophysiology
Neuroimaging 42% CBF, atrophy Psychoactive drugs 3-11 fold RR delirium Related to surgery multifactorial Biomarkers serum anticholinergic activity Neurotransmitters imbalance in all monoamines, GABA, glutamate and Ach Sepsis: blood brain barrier breakdown or damage by metabolic/inflammatory mediators
Yokota. Psych.Clin.Neurosci 2003, Fong. J Geront A Biol Sci Med Sci 2006, Koponen J Nerv Ment Dis 1989, Hopkins Brain Inj 2006, Chang R Neurosig 2006 Inoyue Am J Med 1999, Pandharipande Anesth 2006, Marcantonio JAMA 1994 Tune Lancet 1981, Mussi J Geriatri Psych Neurol 1999, Marcantonio J Geront A Biol Sci Med Sci 20 Goyette Semin Resp CCM 2004, Sharshar ICM 2007
The vast majority of delirium in ICU is either hypoactive quiet subtype (35%) or mixed (64%) Very little (1%) is the pure hyperactive subtype. Older age is a strong predictor of hypoactive delirium Hypoactive delirium has worse outcomes Onset: ICU day 2 (+/- 1.7) How long: 4.2 (+/- 1.7) days
Ely et al JAMA 2001;286:2703-2710 Ely et al CCM 2001;9:1370-1379 Peterson et al JAGS 2006 in press McNicholl JAGS 2003;51:591-598
Risk factors
Host factors Elderly Co-morbidities Pre-existing cognitive impair Hearing/vision impairment Neurological dis Acute illness Severe sepsis ARDS MODS Iatro/environ Sedative/analges Immobilisation TPN
Precipitating factors
INFECTION Hyponatraemia Temperature Maintenance of arterial pressure Glucose Benzodiazepines Hypoxia, hypercarbia
Does it matter?
After adjusting for age, gender, race, pre-existing comorbidity & cog impairment, ICU diagnosis and severity of illness 3 fold higher rate of death by 6 months 1.6 fold increase in ICU costs. Longer hospital stays Nearly 10x rate cognitive impairment on discharge. 1 in 3 survivors with delirium develop cognitive impairment. Institutionalisation
Does it matter?
Increased ICU LOS 8 vs. 5 days Increased Hosp. LOS 21 vs. 11 days Increased time on vent 9 vs. 4 days Higher costs $22 000 vs. $13 000 3 fold increased risk of death Poss. incrd longterm cognitive impairment
Ely ICM 2001;27,1892-1900, Ely JAMA 2004;291:1753-1762, Lim SM, CCM 2004;32:2254-2259, Milbrandt E, CCM 2004;32:955-962, Jackson Neuropsychology Review 2004;14:87-98
Neurological monitoring
Level of sedation. Drugs are given with specific agreed target of effect. Screen for delirium Confusion assessment method for the ICU CAM-ICU, sensitivity/specificity 95% V. high inter-rater reliability
Ely et al CCM;29:1370-1379, 2001, Ely et al JAMA;286:2703-2710, 2001
Delirium screening
CAM-ICU 4 features
Altered mental status Inattention; Indentify As in 10 letter spoken sequence
SAVE A HAART
Disorganised thinking
ICDSC 8 items
Over one shift. 4 or more = delirium
Ely JAMA 2001, Bergeron ICM 2001
CAM-ICU
Incorporates 4 key features from definition of delirium, 1 minute to do 1. Change in mental status from baseline or fluctuating course. 2. Inattention 3. Disorganised thinking 4. Altered level of consciousness Needs 1 & 2 with either 3 or 4.
Feature 2: Inattention
AND
OR
CAM-ICU
Sedation level at least eye-opening to voice with or without eye contact. Feature 1: is patient different from baseline? Or: any fluctuations in mental status 24/12? Feature 2: looking for inattention ASE letters, if unclear status ASE pictures using hand squeeze. If both positive: Feature 3: Disorganised thinking, a) 4 questions 2 or more incorrect responses is positive. b) Holding up fingers. Feature 4: Altered conscious level i.e. drowsy +
Treat underlying infection and CCF Correct metabolic disturbance & hypoxia Frequent reorientation of patient Goal directed sedation/analgesia &/or daily wakeup. Stop ventilator each day to test readiness Early mobilisation Attention to optimising sleep patterns
Inouye. NEJM 1999;340(9):669
Haloperidol
1950 shortly after chlorpromazine D2 blockade mesolimbic pathways Blockade in nigrostriatal pathway EPS Fewer vasomotor, cardiac central effects 60% bioavailability Metabolised by oxidative dealkylation Various dose schedules 2.5mgs to 5mgs starting dose
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