Delirium: Difference between revisions

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

Drugs
- Iatrogenic
  - Polypharmacy
  - Opioids (too much or too little)
  - Diphenhydramine
  - Benzodiazepines
- Abuse: alcohol
- Poisoning
- Withdrawal
  - Alcohol
  - 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's, 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

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 (e.g. dexamethasone)

Antipsychotics

Mild
- Elderly: haloperidol 0.5 mg PO/SQ/IV/IM q4h prn
- End-of-life: haloperidol 0.5-1 mg po or subcut daily or BID + haloperidol 0.5-1 mg po/SC q1h prn
Moderate
- Haloperidol 2-2.5 mg po/sc bid or tid + haloperidol 2 mg po/sc q1h prn
- Or methotrimeprazine 5-12.5 mg po/sc bid or tid + prn
Severe
- Elderly: haloperidol 1 mg, or quetiapine 12.5 mg if long QT
- Midazolam 2.5-5 mg sc stat once + haloperidol 5 mg sc stat
- Or methotrimeprazine 25 mg sc stat then po/sc
- Follow with haloperidol 2.5-5 mg sc q30min prn (max 10-15 mg/day)
Sundowning
- Methotrimeprazine qhs
Alternatives

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

@@ Line 44: / Line 44: @@
 **Endocrine: thyroid, parathyroid, pancreas, pituitary, adrenals
 **Electrolytes: sodium, calcium, magnesium, potassium
-**Hypoglycemia/hyperglycemia
+**[[Hypoglycemia]]/[[hyperglycemia]]
-**Hypoxemia/Hypercarbia
+**[[Hypoxemia]]/[[hypercarbia]]
-**Hypoosmolar/Hyperosmolar
+**Hypoosmolar/hyperosmolar
-**Inborn errors of metabolism: porphyria, Wilson's disease
+**Inborn errors of metabolism: [[porphyria]], [[Wilson disease]]
 **Nutrition: [[Wernicke encephalopathy|Wernicke's]], [[Vitamin B12 deficiency|B12 deficiency]], [[niacin deficiency]]
 *Environmental
-**Surroundings, room changes
+**Surroundings, room changes, lack of sunlight indicating day & night
 *Structures &amp; organs
 **CNS
 ***[[Stroke]]
 ***Brain injury
-***Seizure
+***[[Seizure]]
 **Cardiac: [[heart failure]]
 **Renal: [[AKI]]/[[CKD]]
@@ Line 71: / Line 71: @@
 **Dose reduction
 **Hydration
-*Medications: Stop medication
+*Medications: stop medication
-*Dehydration: IV or Hypodermoclesis (fluid given subcutaneously)
+*Dehydration: IV or [[hypodermoclesis]] (fluid given subcutaneously)
-*Hypercalcemia: IV bisphosphonate (zoledronate/pamidronate)
+*[[Hypercalcemia]]: IV [[bisphosphonate]] ([[zoledronate]]/[[pamidronate]])
-*Infection: Antibiotics
+*Infection: antibiotics
-*Hepatic encepalopathy: Lactulose
+*[[Hepatic encepalopathy]]: [[lactulose]]
-*Brain metastases: Corticosteroids
+*Brain metastases: [[corticosteroids]] (e.g. [[dexamethasone]])
+==== Antipsychotics ====
+*Mild
+**Elderly: [[haloperidol]] 0.5 mg PO/SQ/IV/IM q4h prn
+**End-of-life: [[haloperidol]] 0.5-1 mg po or subcut daily or BID + [[haloperidol]] 0.5-1 mg po/SC q1h prn
+*Moderate
+**[[Haloperidol]] 2-2.5 mg po/sc bid or tid + [[haloperidol]] 2 mg po/sc q1h prn
+**Or [[methotrimeprazine]] 5-12.5 mg po/sc bid or tid + prn
+*Severe
+**Elderly: [[haloperidol]] 1 mg, or [[quetiapine]] 12.5 mg if long QT
+**[[Midazolam]] 2.5-5 mg sc stat once + [[haloperidol]] 5 mg sc stat
+**Or [[methotrimeprazine]] 25 mg sc stat then po/sc
+**Follow with [[haloperidol]] 2.5-5 mg sc q30min prn (max 10-15 mg/day)
+*Sundowning
+**[[Methotrimeprazine]] qhs
+*Alternatives
+**[[Quetiapine]]
+**[[Risperidone]]
+**[[Olanzapine]]
 ===Non-pharmacologic===
@@ Line 85: / Line 104: @@
 *Correct sensory deficits (glasses, hearing aids)
 *Gentle, repeated reassurances (but labour intensive)
-*Do not use physical restraints Pharmacologic Mild
+*Do not use physical restraints
-*Elderly: Haloperidol 0.5mg PO/SQ/IV/IM q4h prn
-*End-of-life: Haloperidol 0.5-1mg po or subcut daily or BID + haloperidol 0.5-1mg po/SC q1h prn Moderate
-*Haloperidol 2-2.5mg po/sc bid or tid + haloperidol 2mg po/sc q1h prn
-*Or methotrimeprazine 5-12.5mg po/sc bid or tid + prn Severe
-*Elderly: haloperidol 1mg, or quetiapine 12.5mg if long QT
-*Midazolam 2.5-5mg sc stat once + haloperidol 5mg sc stat
-*Or methotrimeprazine 25mg sc stat then po/sc
-*Follow with haloperidol 2.5-5mg sc q30min prn (max 10-15mg/day) Subdowning
-*Methotrimeprazine qhs Alternatives
-*Quetiapine
-*Risperidone
-*Olanzapine
 ==RASS Scale==