 Hi, I'm Dr. Aaron Pinkasoff, Chairman of the Department of Behavioral Health at NYU Winter Hospital. Today, you will learn about delirium. After this program, you will be able to define science and types of delirium, identify common etiology and risk factors for delirium, and describe prophylaxis and treatment interventions for delirium. This is Delirium. Delirium is the most common neuropsychiatric syndrome seen in general hospitals. More than 7 million hospitalized Americans suffer from delirium each year. Delirium is present in 50% of older hospitalized patients and unfortunately is missed. In about 60% of cases, estimated national healthcare costs attributed to delirium are now up to $164 billion dollars every year. Delirium can cause permanent cognitive decline and can accelerate dementia. Today, you will be learning about delirium. Throughout this training, you will be watching the experience of Mr. Jones, a 72-year-old who was brought in by his daughter for acute change in his mental status. Hello, I'm Dr. Green. Tell me what brings your father to the hospital today. My dad's been acting strange since last night. Yesterday during the day, I noticed he was anxious and irritable, which is so unlike him. And then he called me last night around 1 a.m. saying that he was screaming about children, making noise and running around, and I know that's impossible because he lives alone. I got really worried and I went over to his house and I found him up and dressed and shaving and saying he was late for work. Doctor, he's been retired for seven years now. So he's been functioning independently up until last night. Have you noticed any problems with his memory at all? After his stroke two years ago, I noticed that he did repeat himself and maybe asked the same question again and again. He also forgot to pay his bills for a couple of months, but I thought maybe that was nothing unusual for someone his age. This is just happening so fast. I just saw him the day before and we had a great conversation. He was doing the crossword puzzles. Okay, well let's check the chart. So your father is 72 years old and you brought him in due to the sudden change of his mental status. His past medical history significant for remote stroke, atrial fibrillation, hypertension, diabetes, osteoarthritis and benign prostate enlargement. Now I do see he is still on meds, including Traumadol and Dejaxa, which by the way can't cause confusion. And let's see, his vitals are showing a low grade fever. Pulse, breathing, BP are slightly elevated. And the CD does show the old stroke that you mentioned, but no new changes. So I can say that there is no new sign of a stroke, which is good, but his vital signs and his blood and urine results do indicate your father has a urinary tract infection and a urinary tension now. We've relieved the blockage by placing a fully catheter and starting up on antibiotics for the UTI. With that, I can say that I think he'll be fine in no time. Mr. Jones, what are you doing? They're waiting for me at work. Mr. Jones was started on Ciprofloxacin. He began to show signs of improvement by the second day. However, by the evening of day two, he became confused and agitated and the medical resident ordered Lorazepam. Two milligrams, I am. The patient calmed down, but he became more confused during the next 24 hours. 111-10. Snakes! Snakes on me! I don't like snakes! Mr. Jones, can I help you? What are you trying to do to me? Where's my wallet? Call the police! Help! Help! I am trying to help you. Get away! I need help in here! Someone call security! Thank goodness he's so much calmer. I heard he was wild last night. That's what I heard, too. Now he's so groggy that I had to wake him up while he was using a bedpan. Let him sleep as much as he wants. We'll make sure to keep the hall quiet as well. This patient's mental status changes are consistent with delirium. Delirium has been described in literature under different names, such as sundowning and ICU psychosis. There are five criteria that must be met for delirium to be diagnosed, as outlined in the DSM-5, disturbance in attention, imperitability to focus, sustain, or shift attention, and awareness. Impaired orientation to environment compared to the patient's baseline. Mr. Jones, what are you doing? Get away from me! They're waiting for me at work. Acute onset over a short period of time, sometimes in just hours or days. This is just happening so fast. I just saw him the day before, and we had a great conversation. And fluctuation throughout the day. I heard he was wild last night. That's what I heard too. Now he's so groggy that I had to wake him up while he was using a bedpan. Additional disturbances in cognition, whether in memory or language, or visual spatial ability, or perceptions of reality. Snakes! Snakes on me! I don't like snakes! The change in cognition or the development of a perceptual disturbance is not due to a pre-existing or evolving problem, such as Alzheimer's or stroke. There is no new sign of a stroke, which is good. Evidence from patient history, physical exam, or labs that this disturbance is caused by a medical condition, substance intoxication or withdrawal, or a medication side effect. His vital signs and his blood and urine results do indicate your father has urinary tract infection. Delirium is seen in three types. Hypoactive, which is the most common, up to 70% of patients. Hypoactive is commonly missed and has poor prognosis. Patients are usually quiet and drowsy. Example, hepatic encephalopathy, hypercarbia. Hyperactive, up to 20% of patients. Patients are usually agitated and restless. Example, alcohol or drugs, intoxication and withdrawal. Mixed, up to 56% of patients fluctuating between hyper and hypoactive. Dementia is the most common risk factor for delirium and is more prevalent as people age. The risk of developing delirium in patients with dementia is five times higher compared to the general population. As the number of medical comorbidities increase, so does the probability of developing delirium. The most important predisposing factors of delirium are, in order, advanced age. History of brain disorders such as dementia, stroke or Parkinson's disease. Multiple medical comorbidities. History of previous episodes of delirium. Hearing or vision impairment. Alcohol and or benzodiazepine use. Patients with delirium stay much longer in the hospital compared to those without delirium, even though they may have an identical medical problem list. Patients with delirium stay in intensive care units on average 10 days longer compared to patients without delirium, and that is over 100% increase in length of stay in the ICU. The rate of mortality in patients with delirium is staggering. 14% of patients die within the first month. 25% in six months and 50% within two years. The recognition and early treatment of delirium is critical as delirium can lead to long-lasting decline in health and functional status. Those who survive show significant decline in their functional level. In a study of older patients after orthopedic surgery, you could see both cognitively intact patients and patients with dementia preserve their level of activity of daily living if they don't develop postoperative delirium. However, once delirium is superimposed on pre-existing cognitive deficits, their functional status declines and may not go back to preoperative baseline. For that reason, patients who survive delirium are at much higher risk of need for nursing home placement. To emphasize the high mortality risk, we will use the mnemonic I watch death to learn about the possible causes of delirium. I stands for infection, such as a urinary tract infection, similar to the patient we described in our example. Other infections can include pneumonia and skin infection. W stands for withdrawal from substances such as alcohol and sedative hypnotics. A stands for acute metabolic changes such as electrolyte disturbances or abnormal blood sugar. T is for trauma as delirium is commonly seen in head injuries or during postoperative states. C stands for central nervous system pathology such as stroke or Parkinson's disease. H stands for hypoxia from causes like asthma or anemia. D stands for deficiencies from essential vitamins such as vitamin B12 and thiamine. E for endocrinopathies such as hyper or hypo thyroid states. A stands for acute vascular conditions such as hypertensive encephalopathies. T stands for toxic substances such as illicit drugs, alcohol or medications, whether prescribed or over the counter. And finally H stands for heavy metals such as lead. On a molecular level, neurotransmitters and hormone imbalances have been implicated in delirium such as acetylcholine, GABA, dopamine, melatonin, and serotonin. More specifically, studies have demonstrated that lower levels of acetylcholine and excess amounts of dopamine may be involved in delirium. Moreover, it provides the rationale for use of antipsychotic medications as one treatment strategy. Here you see the comparison between two intensive care survivors. Both are women in their 40s who are being treated for acute respiratory distress syndrome. Both were similar in terms of medical comorbidity and had no pre-existing history of cognitive deficits. Patient A, who had no delirium, does not show any brain volume loss. While patient B, who experienced 12 days of delirium during her ICU stay, shows significant atrophy of her brain, even though she was four years younger. In general, the longer patients remain in delirium, the greater the risk for brain volume loss and permanent cognitive impairment. At NYU Winthrop Hospital, we developed the ACE intervention to ensure a comprehensive non-pharmacological approach to delirium management. This intervention addresses three vital areas activity, comfort, and environment. Starting with activity. If possible, take the time to get patient out of bed and walk with your patients. Encourage your patients to participate in physical therapy. Use simple, cognitively stimulating activities to promote and enhance thinking. Provide frequent reorientation to time and place. Comfort measures should be addressed by ensuring adequate nutrition, regular bowel and bladder functions, and promoting natural sleep cycles. Unless critical, avoid doing vital signs and blood work between 10 p.m. and 6 a.m. to improve sleep. Using patients' assistive devices such as hearing aids, eyeglasses, and dentures will help with orientation and reduce frustration. Remove catheters whenever possible and provide cautious but adequate pain control. As for the environment, make patients comfortable by minimizing disturbances and speaking in a simplified language with a calm tone. Encourage family presence and familiar atmosphere using family pictures and favorite music. Maximizing natural sunlight, minimizing artificial lights, promoting a quiet, calm environment is an effective way to minimize delirium. It's been four days and Mr. Jones is still confused and agitated. I brought psychiatry and board to help us manage his behavior. Now, we've given Mr. Jones a lorazepam to help us calm him down, but the situation still is not improving. In fact, I think he's getting worse. Medications like benzodiazepines, anticholinergics, and opiates can actually cause or prolong delirium. My first recommendation is to avoid using those medications as much as possible. These medications were proven to be useful in patients with agitated delirium. Quetiapine, by mouth, Resperidone, by mouth, Haloperidol, by mouth, or IM. Haloperidol may also be given IV with telemetry monitoring. When we use these medications, we should watch out for QTC prolongation, and in the case of Haloperidol and Resperidone, the Parkinson's symptoms. There is no clear evidence to recommend routine use of antipsychotics in hypoactive delirium at this time. Mr. Jones, looks like you're doing quite well. Please follow up with your primary physician and watch out for any sudden changes in your ability to think clearly. That might indicate a newly developing medical problem. Doctors, these last few weeks have been really scary. I have been quite myself. But I feel much better now. Thank you. As you can see, a timely and comprehensive approach to patients with delirium is extremely important to safeguard their quality of life and life itself.