What about the physical examination of the delirious patient?

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Delirium
A Patient-Centered, Evidence-Based Diagnostic
and Treatment Process1,2
Kendall L. Stewart, MD, MBA, DLFAPA
April 19, 2013
1My
aim is to offer practical clinical insights that you can use right away in caring for patients.
let me know whether I have succeeded on your evaluation forms.
2Please
Why is this important?
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This is common and it is serious.
14-56% of hospitalized elderly
patients have delirium.1,2
40% of ICU patients are delirious at
some point during their stays.
As many as 42% of post-operative
orthopedic patients become delirious.
As many as 80% of patients become
delirious near death.
Patients who become delirious during
their hospitalizations have mortality
rates of 22-76%.
Delirium may produce prolonged
hospital stays, increased
complications, increased costs and
long-term disability.
1Hospitalists
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After mastering the information in
this presentation, you will be able
to
– Identify the other diagnoses in this
category,
– Identify the diagnostic criteria for
delirium,
– Specify three disorders that may
produce delirium,
– Describe the evaluation of the
patient with delirium,
– Discuss a differential diagnosis,
– Write a typical treatment plan, and
– Explain some of the typical
treatment challenges.
and others are now deploying protocols for preventing delirium in inpatients.
Inouye, Sharon, “A Practical Program for Preventing Delirium in Hospitalized Elderly Patients,” Cleveland Clinic Journal
of Medicine, November 2004
2See
What other disorders are included in
the cognitive disorders category?
• Delirium
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Delirium Due to a General Medical Condition
Substance Intoxication Delirium
Substance Withdrawal Delirium
Delirium Due to Multiple Etiologies
Delirium Not Otherwise Specified (NOS)
• Dementia
• Amnestic Disorders
• Other Cognitive Disorders
How do these patients typically
present?1,2
• “Doctor, this is a 74-year-old
woman.”
• “She has become increasingly
confused, suspicious and
agitated this evening.”
• “Her level of consciousness is
fluctuating.”
• “She is disoriented and it
appears to irritate her when I
ask the orientation questions.”
• “She is picking at her gown and
the sheet on her bed.”
• “Sometimes, she mumbles
incoherently and I cannot
understand her.”
1Family
2The
• “Her family members have
never seen her like this and they
are very scared.”
• “She says that her room is full of
rats and that they are biting
her.”
• “She has not been able to sleep
at all.”
• “She has a wild look in her eyes
and she appears frightened.”
• “She recognizes her family
sometimes and sometimes she
doesn’t.”
members or caregivers usually provide the histories.
diagnosis of delirium is usually easy to make; figuring out what is wrong is another matter altogether.
What are the diagnostic criteria for
delirium?
• The patient experiences a
disturbance of consciousness
with reduced ability to focus,
sustain, or shift attention.
• There is a change in cognition
(such as a memory impairment,
disorientation, problem with
language) or the development of
a perceptual disturbance that is
not better explained by
dementia.
• The disturbance develops over a
relatively short period of time
and tends to fluctuate during
the course of the day.
• There is evidence from the
history of the cause of the
delirium (or there is not).
• (If the etiology cannot be
established or strongly
suspected, the proper diagnosis
is Delirium Not Otherwise
Specified).
What are some of the causes of
delirium?
• Infection (meningitis, encephalitis,
systemic infection)
• Withdrawal (alcohol, benzodiazepines,
barbiturates)
• Acute Metabolic Disturbances
• Hypoxia (anemia, cardiac failure,
respiratory failure, hypotension,
pulmonary embolus, carbon monoxide
poisoning)
• Deficiencies (vitamin B12, folate,
thiamine)
(electrolyte and acid-base
abnormalities, renal disease, hepatic
disease, postoperative state)
• Endocrinopathies (hyper- or
burns)
• Acute Vascular (septic shock,
• Trauma (concussion, heat stroke severe
• CNS pathology (cerebrovascular
accident, seizure, subdural or
subarachoid hemorrhage, neoplasms,
infections)
hypothyroidism, hyper- or
hypocortisolism, hypoglycemia)
hypertensive encephalopathy)
• Toxins or drugs (amphetamines,
anticholinergics, anticonvulsants,
clonidine, digitalis, hallucinogens)
• Heavy Metals (arsenic, lead,
manganese, mercury)
1Every
psychiatrist memorizes “I WATCH DEATH” or some similar mnemonic for Board exams.
Slide 1 of 6
What about the physical examination
of the delirious patient?
Parameter
Finding
Clinical Implication
Pulse
Bradycardia
Hypothyroidism
Stokes-Adams syndrome
Increased intracranial pressure
Temperature
Fever
Sepsis
Thyroid storm
Vasculitis
Blood Pressure
Hypotension
Shock
Hypothyroidism
Addison’s disease
Blood Pressure
Hypertension
Encephalopathy
Intracranial mass
Slide 2 of 6
What about the physical examination
of the delirious patient?
Parameter
Finding
Clinical Implication
Respiration
Tachypnea
Diabetes
Pneumonia
Cardiac failure
Fever
Respiration
Shallow
Alcohol or other substance
intoxication
Carotid vessels
Bruits or decreased pulse
Transient cerebral ischemia
Scalp and face
Evidence of trauma
Trauma
Slide 3 of 6
What about the physical examination
of the delirious patient?
Parameter
Finding
Clinical Implication
Neck
Evidence of nuchal rigidity
Meningitis
Subarachoid hemorrhage
Eyes
Papilledema
Tumor
Hypertensive encephalopathy
Eyes
Pupillary dilatation
Anxiety
Autonomic hyperactivity
Delirium tremens
Mouth
Tongue or cheek lacerations
Tonic-clonic seizures
Slide 4 of 6
What about the physical examination
of the delirious patient?
Parameter
Finding
Clinical Implication
Thyroid
Enlarged
Hyperthyroidism
Heart
Arrhythmia
Inadequate cardiac output
Possible emboli
Heart
Cardiomegaly
Heart failure
Hypertension disease
Lungs
Congestion
Primary pulmonary failure
Pulmonary edema
Pneumonia
Slide 5 of 6
What about the physical examination
of the delirious patient?
Parameter
Finding
Clinical Implication
Breath
Alcohol
Ketones
Diabetes
Liver
Enlargement
Cirrhosis
Liver failure
Reflexes
Muscle stretch
Asymmetry with Babinski’s
signs
Mass lesion
Cerebrovascular disease
Pre-existing dementia
Reflexes
Snout Reflex
Frontal mass
Bilateral posterior cerebral
artery occlusion
Slide 6 of 6
What about the physical examination
of the delirious patient?
Parameter
Finding
Clinical Implication
Sixth cranial nerve
Weakness in lateral gaze
Increased intracranial pressure
Limb strength
Asymmetrical
Mass lesion
Cerebrovascular disease
Autonomic
Hyperactivity
Anxiety
Delirium
What should be included in the
laboratory workup for delirium?
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Standard studies
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When indicated
– Blood chemistries (including electrolytes, renal and hepatic
indexes, and glucose)
– Complete blood count with white cell differential
– Thyroid function tests
– Serologic tests for syphilis
– Human immunodeficiency virus (HIV) antibody test
– Urinalysis
– Electrocardiogram
– Chest radiograph
– Blood and urine drug screens
– Blood, urine, and cerebrospinal fluid (CSF) cultures
– B12, folic acid levels
– Computed tomography or magnetic resonance imaging brain
scan
– Lumbar puncture and CSF examination
What are some of the differential
diagnoses?
• Dementia
• Delirium
– Due to a general medical
condition
– Due to substance intoxication
– Due to substance withdrawal
– Due to multiple etiologies
– Not otherwise specified
• Substance Intoxication
• Substance Withdrawal
• Brief Psychotic Disorder
• Schizophrenia
• Mood Disorder with
Psychotic Features
• Acute Stress Disorder
• Anxiety Disorder
• Malingering
• Factitious Disorder
• Cognitive Disorder Not
Otherwise Specified
What are the differences between
delirium and dementia?
Features
Delirium
Dementia
Onset
Acute
Insidious
Course
Fluctuating
Progressive
Duration
Days to Weeks
Months to Years
Consciousness
Altered
Clear
Attention
Impaired
Normal until dementia is
severe
Psychomotor Changes
Increased or decreased
Often normal
Reversibility
Usually
Rarely
What might be included in a typical
treatment plan?
• General Principles
– Treat the underlying cause.
– This often means stopping some of
the patient’s medications.
– Avoid adding medication if
possible.
– Sedate if necessary.
– Observe the patient briefly to
confirm the presence of delirium,
then obtain a history from family
members or caregivers.
– Reassure family members.1,2
– Provide physical, sensory and
environmental support.
– Arrange for a relative or friend sit
with them.
– Provide soft lighting and
orientation cues.
1The
• Pharmacotherapy
– Haloperidol (Haldol) 2-10 mg IM
repeated hourly is still pretty much
the gold standard.
– Avoid the phenothiazines because
of their anticholinergic toxicity.
– Physostigmine salicylate
(Antilirium) IM or IV can be
repeated every 15-30 minutes for
anticholinergic toxicity.
– Avoid over-sedation.
– Use short half-life benzodiazepines
such as lorazepam (Ativan) 1-2 mg
if necessary for sleep. Avoid the
long half-life benzodiazepines.
– The benzodiazepines are
particularly helpful in alcohol
withdrawal syndromes.
last time I came to the hospital in the middle of the night was to treat a delirious patient.
I left, I felt I had really made a difference.
2When
What are some of the typical treatment
challenges?
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These patients usually cannot
contribute meaningfully to the
history.
Questioning them just causes more
agitation.
Families are usually very upset,
scared and sometimes panicked,
distracted and suspicious.
It is rarely clear what exactly is
causing the problem.
These patients cause real
management problems for nurses
and other caregivers.
The problem is usually worse at
night, i.e., “sun downing” (This
problem is not specific to delirium.)
A delirium is a relative emergency.
1What
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Restless, fearfulness and mild
paranoia are frequent harbingers of
worse things to come.
Patients’ memories are spotty
afterwards and embarrassment is
common.1,2
Irritability encourages hatefulness
and hurt feelings often result.
appears to be an obvious delusion sometimes turns out to be reality.
patient in the ICU once told me he had worked on his electric fence the prior evening.
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Treatment Process
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Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of my problems and
concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
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Review my laboratory data and other
available records.
Tell me what diagnoses you have made.
Reassure me.
Outline your recommended treatment plan
while making sure that I understand.
Repeatedly invite my clarifying questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any additional
questions I may have.
Make a follow up appointment.
Communicate with my other physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
1
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Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry,
Third Edition, 20081
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology,
April 20072
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry
Clerkship, Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review,
Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at
Home, Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Where can you find evidence-based
information about mental disorders?
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American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition,
2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry,
2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second
Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth
Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January
2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work
and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000
Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.
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