Delirium: Difference between revisions

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== Definition ==
==Background==


=== Definition ===
* An acute brain dysfunction syndrome of fluctuating levels of consciousness
* Cardinal features:
** altered mental status and ''fluctuating course''
** ''inattention''
** altered ''level of consciousness'' (i.e. RASS not zero) OR ''disorganized thinking''


*An acute brain dysfunction syndrome of fluctuating levels of consciousness
== Differential Diagnosis ==
*Cardinal features:
**altered mental status and ''fluctuating course''
**''inattention''
**altered ''level of consciousness'' (i.e. RASS not zero) OR ''disorganized thinking''


==Differential Diagnosis==
=== Life-threatening causes (WHHHHIMPS) ===


===Life-threatening causes (WHHHHIMPS)===
* Wernicke's or EtOH withdrawal
* Hypoxia/Hypercarbia
* Hypoglycemia
* Hypertensive emergency
* Hyperthermia/Hypothermia
* Intracerebral hemorrhage
* Meningitis/Encephalitis
* Poisoning
* Status epilepticus


*[[Wernicke encephalopathy|Wernicke's]] or [[alcohol withdrawal]]
=== DIMES ===
*[[Hypoxia]]/[[hypercarbia]]
*[[Hypoglycemia]]
*[[Hypertensive crisis|Hypertensive emergency]]
*Hyperthermia/[[hypothermia]]
*Intracerebral hemorrhage
*[[Meningitis]]/[[encephalitis]]
*Poisoning
*[[Status epilepticus]]


===DIMES===
* Drugs
** Iatrogenic
*** Polypharmacy
*** Opioids (too much or too little)
*** Diphenhydramine
*** Benxodiaepines
** Abuse
*** Alcohol
** Poisoning
** Withdrawal
*** Alcohol
*** Benzodiazepines
* Infections
** Septicemia
** Pneumonia
** Urinary tract infection
** Skin infection or ulcer
* Metabolic
** Endocrine: thyroid, parathyroid, pancreas, pituitary, adrenals
** Electrolytes: sodium, calcium, magnesium, potassium
** Hypoglycemia/hyperglycemia
** Hypoxemia/Hypercarbia
** Hypoosmolar/Hyperosmolar
** Inborn errors of metabolism: porphyria, Wilson's disease
** Nutrition: Wernicke's, B12 deficiency, niacin deficiency
* Environmental
** Surroundings, room changes
* Structures & organs
** CNS
*** Stroke
*** Brain injury
*** Seizures
** Cardiac: heart failure
** Renal: AKI/CKD
** Gastrointestinal: constipation, volvulus
** Genitourinary: retention


*Drugs
== Management ==
**Iatrogenic
***Polypharmacy
***[[Opioids]] (too much or too little)
***[[Diphenhydramine]]
***[[Benzodiazepines]]
**Abuse: [[Alcohol use disorder|alcohol]]
**Poisoning
**Withdrawal
***[[Alcohol withdrawal|Alcohol]]
***[[Benzodiazepine withdrawal|Benzodiazepine]]
*Infections
**[[Sepsis]]
**[[Pneumonia]]
**[[Urinary tract infection]]
**[[Skin and soft tissue infection]] or ulcer
*Metabolic
**Endocrine: thyroid, parathyroid, pancreas, pituitary, adrenals
**Electrolytes: sodium, calcium, magnesium, potassium
**[[Hypoglycemia]]/[[hyperglycemia]]
**[[Hypoxemia]]/[[hypercarbia]]
**Hypoosmolar/hyperosmolar
**Inborn errors of metabolism: [[porphyria]], [[Wilson disease]]
**Nutrition: [[Wernicke encephalopathy|Wernicke's]], [[Vitamin B12 deficiency|B12 deficiency]], [[niacin deficiency]]
*Environmental
**Surroundings, room changes, lack of sunlight indicating day & night
*Structures & organs
**CNS
***[[Stroke]]
***Brain injury
***[[Seizure]]
**Cardiac: [[heart failure]]
**Renal: [[AKI]]/[[CKD]]
**Gastrointestinal: [[constipation]], [[volvulus]]
**Genitourinary: [[urinary retention]]


==Management==
Treat underlying causes


* Treat underlying causes
=== Pharmacologic ===


===Pharmacologic===
* Opioid neurotoxicity:
** Switch opioid
** Dose reduction
** Hydration
* Medications: Stop medication
* Dehydration: IV or Hypodermoclesis (fluid given subcutaneously)
* Hypercalcemia: IV bisphosphonate (zoledronate/pamidronate)
* Infection: Antibiotics
* Hepatic encepalopathy: Lactulose
* Brain metastases: Corticosteroids


*Opioid neurotoxicity:
=== Non-pharmacologic ===
**Switch opioid
**Dose reduction
**Hydration
*Medications: stop medication
*Dehydration: IV or [[hypodermoclesis]] (fluid given subcutaneously)
*[[Hypercalcemia]]: IV [[bisphosphonate]] ([[zoledronate]]/[[pamidronate]])
*Infection: antibiotics
*[[Hepatic encepalopathy]]: [[lactulose]]
*Brain metastases: [[corticosteroids]] (e.g. [[dexamethasone]])


==== Antipsychotics ====
* Reduce stimulation
*Mild
* Low ambient light
**Elderly: [[haloperidol]] 0.5 mg PO/SQ/IV/IM q4h prn
* Low noise
**End-of-life: [[haloperidol]] 0.5-1 mg po or subcut daily or BID + [[haloperidol]] 0.5-1 mg po/SC q1h prn
* Correct sensory deficits (glasses, hearing aids)
*Moderate
* Gentle, repeated reassurances (but labour intensive)
**[[Haloperidol]] 2-2.5 mg po/sc bid or tid + [[haloperidol]] 2 mg po/sc q1h prn
* Do not use physical restraints Pharmacologic Mild
**Or [[methotrimeprazine]] 5-12.5 mg po/sc bid or tid + prn
* Elderly: Haloperidol 0.5mg PO/SQ/IV/IM q4h prn
*Severe
* End-of-life: Haloperidol 0.5-1mg po or subcut daily or BID + haloperidol 0.5-1mg po/SC q1h prn Moderate
**Elderly: [[haloperidol]] 1 mg, or [[quetiapine]] 12.5 mg if long QT
* Haloperidol 2-2.5mg po/sc bid or tid + haloperidol 2mg po/sc q1h prn
**[[Midazolam]] 2.5-5 mg sc stat once + [[haloperidol]] 5 mg sc stat
* Or methotrimeprazine 5-12.5mg po/sc bid or tid + prn Severe
**Or [[methotrimeprazine]] 25 mg sc stat then po/sc
* Elderly: haloperidol 1mg, or quetiapine 12.5mg if long QT
**Follow with [[haloperidol]] 2.5-5 mg sc q30min prn (max 10-15 mg/day)
* Midazolam 2.5-5mg sc stat once + haloperidol 5mg sc stat
*Sundowning
* Or methotrimeprazine 25mg sc stat then po/sc
**[[Methotrimeprazine]] qhs
* Follow with haloperidol 2.5-5mg sc q30min prn (max 10-15mg/day) Subdowning
* Methotrimeprazine qhs Alternatives
*Alternatives
* Quetiapine
**[[Quetiapine]]
* Risperidone
**[[Risperidone]]
* Olanzapine
**[[Olanzapine]]


===Non-pharmacologic===
== RASS Scale ==

*Reduce stimulation
*Low ambient light
*Low noise
*Correct sensory deficits (glasses, hearing aids)
*Gentle, repeated reassurances (but labour intensive)
*Do not use physical restraints

==RASS Scale==


[[Category:Neurology]]
[[Category:Neurology]]

Latest revision as of 15:01, 26 June 2022

Background

Definition

  • An acute brain dysfunction syndrome of fluctuating levels of consciousness
  • Cardinal features:
    • altered mental status and fluctuating course
    • inattention
    • altered level of consciousness (i.e. RASS not zero) OR disorganized thinking

Differential Diagnosis

Life-threatening causes (WHHHHIMPS)

DIMES

Management

  • Treat underlying causes

Pharmacologic

Antipsychotics

Non-pharmacologic

  • Reduce stimulation
  • Low ambient light
  • Low noise
  • Correct sensory deficits (glasses, hearing aids)
  • Gentle, repeated reassurances (but labour intensive)
  • Do not use physical restraints

RASS Scale

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