Delirium

Delirium
• Delirium is a mental state in which pt is
confused, disoriented, and not
able to think or remember clearly.
• It usually starts suddenly.
• It is often temporary and treatable.
 Delirium Causes
Medical Conditions
• Delirium can result from underlying medical
issues, such as infections (urinary tract
infections, pneumonia)
• Metabolic imbalances (electrolyte
abnormalities)
• Organ failure (liver or kidney failure
• Neurological disorders (strokes)
 Delirium
• Dementia
• Cancer
• Infections (including HIV, pneumonia or
COVID-19)
• Sepsis or stroke
• Recent bone fracture
Medications
 Delirium Causes
Substance Abuse
• The misuse of alcohol, drugs, or withdrawal
from them can trigger delirium

• Alcohol withdrawal, in particular, is associated

with a condition called delirium tremens (DT).
 Delirium Causes
• Surgery or Trauma: Delirium can occur after
major surgery or severe physical trauma
• Infections: Infections affecting the brain, such
as encephalitis or meningitis, can lead to
delirium.
• Sleep Deprivation: A lack of sleep or poor
sleep quality can contribute to delirium
 Delirium Causes
• Environment: Natural lighting helps your body
maintain its sense of night and day, and losing
that sense can greatly increase your risk of
developing delirium.

• Sound is another sense that can affect your

sleep/wake cycle.
 Delirium Causes
• People who need hearing aids or eyeglasses
have a higher risk of developing delirium,
especially if they aren’t using these assistive
items.

• Separation or isolation from family, friends

and loved ones can worsen delirium.
 Risks for delirium
• aged over 65 years
• taking multiple medicines or those who have had recent
changes to medicines
• recent surgery
• with depression
• with poor eyesight and/or hearing loss
• very sick or frail
• with a cognitive impairment, including dementia,
intellectual disability or brain injury
• H/O delirium before
 Treatment of Delirium
• Delirium is a complex condition that requires a
multidisciplinary approach involving
healthcare professionals such as
• physicians
• nurses
• psychologists
• pharmacists.
 Treatment of Delirium
• The treatment of delirium involves addressing
the underlying causes

• Delirium is a medical emergency and requires

prompt assessment and intervention
 1. Identification and Management of
Underlying Causes
• Infections: Treat the underlying infection with appropriate
antibiotics or antiviral medications.

• Medication Side Effects: Discontinue or adjust medications that

may be contributing to delirium, especially drugs with sedative
or psychoactive effects.

• Metabolic Disturbances: Correct any imbalances in electrolytes,

glucose levels, or other metabolic factors.

• Dehydration: Administer intravenous fluids to correct

dehydration if necessary.
 1. Identification and Management of
Underlying Causes

• Organ Failure: Manage conditions like liver or

kidney failure that may be contributing to delirium.

• Trauma: Treat any injuries, fractures, or head

trauma that might have occurred.

• Substance Withdrawal: Provide supportive care

and
 2. Medications for Symptomatic
Management:
• Antipsychotic Medications
• Low-dose antipsychotics like haloperidol or
atypical antipsychotics (e.g., quetiapine) may
be prescribed to manage
Severe agitation
Hallucinations
Behavioral disturbances
 2. Medications for Symptomatic
Management
• Benzodiazepines: In cases of delirium caused
by
• Alcohol or sedative withdrawal

Short-acting benzodiazepines may be

administered to manage withdrawal symptoms.
 2. Medications for Symptomatic
Management
• Analgesics:
• Adequate pain management is crucial, as
untreated pain can contribute to delirium.

• Non-opioid analgesics are preferred to avoid

worsening delirium
3. Environmental and Supportive Measures

• Quiet and Calm Environment: Minimize noise and disruptions

in the patient's surroundings to reduce agitation and
confusion.

• Regular Sleep Patterns: Maintain a consistent sleep schedule,

and use strategies to promote sleep, such as reducing
nighttime noise and providing daytime exposure to natural
light.

• Reorientation and Communication: Frequently reorient the

patient to time and place using clear and simple language
when communicating.
3. Environmental and Supportive Measures

• Family and Caregiver Involvement: Support

from family members and caregivers is
essential. They can provide emotional comfort
and help with reorientation.

• Assistance with Activities of Daily Living:

Patients with delirium may struggle with
feeding, dressing, and personal care. Provide
assistance as needed.
 4. Prevention
Preventing delirium is crucial, especially in high-
risk populations, such as older adults in
hospitals. Strategies include:
• Avoiding unnecessary medications.
• Early treatment of infections.
• Monitoring and managing pain.
• Minimizing sedation and immobility.
 Delirium and dementia
• Delirium, dementia and depression can
appear the same.

• Dementia is a condition where a person’s

memory, thinking, understanding or judgment
can be affected. It gets worse with time
• A 78-year-old patient is admitted to the
hospital for a hip fracture repair surgery. On
the second postoperative day, the patient
becomes agitated, disoriented, and
experiences hallucinations. Vital signs are
stable. What is the most likely diagnosis for
this acute change in mental status?
• A 72-year-old patient with a recent diagnosis
of lung cancer is started on chemotherapy.
Shortly after the first cycle of chemotherapy,
the patient develops acute confusion,
agitation, and visual hallucinations. What term
best describes this reversible and fluctuating
disturbance in consciousness?
• A 60-year-old patient with no significant
medical history is brought to the emergency
department with altered mental status. The
patient appears drowsy, with slowed speech
and reduced responsiveness. Laboratory tests
reveal elevated blood alcohol levels. What is
the likely cause of the patient's altered mental
status in this scenario?
 Key facts-WHO
• Currently more than 55 million people have
dementia worldwide, over 60% of who live in
low-and middle-income countries
• Every year, there are nearly 10 million new
cases.
• Dementia results from a variety of diseases
and injuries that affect the brain
 Key facts-WHO
• Alzheimer disease is the most common form
of dementia and may contribute to 60–70% of
cases.
• Dementia is currently the seventh leading
cause of death and one of the major causes of
disability and dependency among older
people globally.
 Key facts-WHO
• In 2019, dementia cost economies globally 1.3
trillion US dollars
• Women experience higher disability-adjusted
life years and mortality due to dementia
• Dementia is the loss of cognitive
functioning
• Thinking
• Remembering
• Reasoning
to such an extent that it interferes
with a person's daily life and activities.
• Dementia is the result of changes
in certain brain regions that cause
neurons (nerve cells) and their
connections to stop working
properly
• Researchers have connected changes in the
brain to certain forms of dementia and are
investigating why these changes happen in
some people but not others
• For a small number of people, rare genetic
variants that cause dementia have been
identified.
 Common Causes and Etiological factors of
dementia
Alzheimer's Disease (AD)

• AD is most common cause of dementia, -significant

majority of cases.
• The exact cause of AD is not fully understood
• Accumulation of abnormal protein deposits, including
beta-amyloid plaques and tau tangles, in the brain
• This leads to neuronal damage and cognitive decline.
Positron emission tomography (PET) scans
produce detailed 3-dimensional images of
the inside of the body.
The images can clearly show the part of
the body being investigated, including any
abnormal areas, and can highlight how
well certain functions of the body are
working.
 Common Causes and Etiological factors of
dementia
Vascular Dementia(VD)
• VD results from impaired blood flow to the
brain, often due to strokes or small vessel
disease.
• The underlying causes include atherosclerosis
(hardening of the arteries), hypertension (high
blood pressure), and cerebrovascular diseases.
 Common Causes and Etiological factors of
dementia
Lewy Body Dementia (LBD):
• LBD is characterized by the presence of
abnormal protein deposits called Lewy bodies
in the brain.
• The exact cause is not well understood
• It shares some similarities with Parkinson's
disease.
 Common Causes and Etiological factors of
dementia
• Frontotemporal Dementia (FTD)

• FTD is caused by the progressive degeneration

of the frontal and temporal lobes of the brain.
• The exact causes can include genetic
mutations, but not all cases are hereditary.
 Frontotemporal Dementia (FTD)

• Unlike Alzheimer's disease, FTD often

manifests at a younger age (typically between
45 and 65)
• Characterized by marked changes in social
conduct, emotional regulation, and
communication abilities, rather than memory
loss in the early stages.
 Common Causes and Etiological factors of
dementia
Mixed Dementia

• Some individuals may have a combination of

different types of dementia, such as
Alzheimer's disease and vascular dementia,
which is referred to as mixed dementia.
 Common Causes and Etiological factors of
dementia
• Parkinson's Disease Dementia: Individuals with
advanced Parkinson's disease can develop
dementia as a complication of the disease.
• Huntington's Disease: A genetic disorder that
leads to progressive brain degeneration and
dementia.
• Creutzfeldt-Jakob Disease: A rare, degenerative,
and fatal brain disorder caused by abnormal
proteins called prions.
 Common Causes and Etiological factors of
dementia
• Traumatic Brain Injury: Severe head injuries
can lead to chronic traumatic encephalopathy
(CTE) and dementia.

• HIV/AIDS: The human immunodeficiency virus

(HIV) can affect the brain, leading to HIV-
associated dementia.
 Medication or Toxin Exposure
• Anticholinergic drugs are a diverse group of
medications that block the action of
acetylcholine, a neurotransmitter in the nervous
system.
• They can be used to treat various conditions,
• Allergies
• GIT disorders
• Overactive bladder
• Parkinson's disease, and motion sickness.
 Medication or Toxin Exposure
• Antihistamine medications:

• Diphenhydramine (Benadryl, Advil PM, Tylenol

PM)
• Chlorpheniramine (Chlor-tab, Aller-Chlor,
Coricidin HBP)
• Doxylamine (Unisom)
 Medication or Toxin Exposure
Tricyclic antidepressants

• Doxepin (Silenor)
• Nortriptyline (Pamelor)
• Amitriptyline (Elavil)
 Medication or Toxin Exposure
Irritable bowel syndrome medications:

• Hyoscyamine (Levsin)
• Dicyclomine (Bentyl)
 Medication or Toxin Exposure
Overactive bladder medications:

• Darifenacin ER (Enablex)
• Oxybutynin (Ditropan)
• Tolterodine (Detrol, Detrol LA)
• Trospium (Sanctura)
• Solifenacin (Vesicare)
• Fesoterodine (Toviaz)
 Medication or Toxin Exposure
Proton pump inhibitors:

• Omeprazole (Prilosec)
• Lansoprazole (Prevacid)
• Esomeprazole (Nexium)
• Pantoprazole (Protonix
 Medication or Toxin Exposure
Opioid medications:

• Morphine
• Hydrocodone (Norco)
• Hydromorphone (Dilaudid)
• Fentanyl (Duragesic)
 Medication or Toxin Exposure
NSAID medications:

• Naproxen (Aleve, Naprosyn)

• Ibuprofen (Motrin, Advil)
• Indomethacin (Indocin)
 Medication or Toxin Exposure
Benzodiazepine medications:

• Lorazepam (Ativan)
• Clonazepam (Klonopin)
• Diazepam (Valium)
• Alprazolam (Xanax, Niravam)
Other Factors

• Age is a significant risk factor for many types of dementia.

As people get older, the risk of developing dementia
increases.
• Genetic factors can play a role in some forms of dementia,
such as early-onset familial Alzheimer's disease.
• Lifestyle factors, including cardiovascular health, diet,
physical activity, and education level, can influence the risk
of dementia.
 Treatment of Dementia
• The treatment of dementia involves a
combination of pharmacological and non-
pharmacological interventions

• Approach can vary depending on the type and

stage of dementia
 Pharmacological Treatment
Alzheimer's Disease:
Cholinesterase Inhibitors: They work by
increasing the levels of acetylcholine, a
neurotransmitter involved in memory and
learning
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Razadyne)
 Pharmacological Treatment
Memantine
• This medication is typically used for moderate
to severe Alzheimer's disease. It regulates the
activity of glutamate, another
neurotransmitter involved in learning and
memory.
 Pharmacological Treatment
Lewy Body Dementia (LBD)

Cholinesterase Inhibitors: These medications

may help manage cognitive and behavioral
symptoms in LBD as they do in Alzheimer's
disease.
 Pharmacological Treatment
Atypical Antipsychotic Medications:
• In some cases, antipsychotic medications like
quetiapine may be used to address
hallucinations and behavioral disturbances,
but they should be used cautiously.
 Pharmacological Treatment
Parkinson's Disease Dementia:

• Medications used to manage Parkinson's

disease symptoms, such as levodopa, may also
help alleviate cognitive symptoms in
individuals with Parkinson's disease dementia.
 Non-Pharmacological Treatments
• Psychosocial Interventions
• Cognitive Stimulation
• Behavioral Interventions
• Support Groups
• Environmental Adaptations
• Physical Exercise and Nutrition
• Occupational and Speech Therapy
• Caregiver Support and Education
 1. Alzheimer’s Disease
• A 75-year-old retired schoolteacher, has begun
forgetting recent events, misplacing items, and
repeating questions within short periods. Over
time, she becomes confused about the time and
date, and starts having difficulty recognizing
familiar people. Her language skills decline, and she
struggles to find the right words in conversations.
As the disease progresses, she becomes disoriented
even in her own home and needs assistance with
basic activities like dressing and bathing.
 Vascular Dementia
• A 68-year-old man, suffered a stroke six months
ago. Since then, he has experienced sudden
memory lapses, poor judgment, and difficulty
focusing on tasks. His personality has changed,
becoming more irritable and short-tempered.
Unlike Alzheimer’s, his symptoms appear
abruptly and worsen after each mini-stroke. He
also struggles with mobility issues, including
unsteady walking, and often needs help with
coordination.
 Lewy Body Dementia
• A 72-year-old retired nurse, begins to experience
vivid visual hallucinations, seeing people who
aren’t there or objects that change shape. She
also shows signs of Parkinsonism, such as
tremors, slow movements, and a shuffling gait.
Her cognitive abilities fluctuate daily—on some
days, she is lucid, while on others, she is confused
and disoriented. Her sleep is disrupted by acting
out dreams, sometimes kicking or talking during
REM sleep.
 Frontotemporal Dementia
• A 45-year-old engineer, begins exhibiting odd
behaviors at work and home. He starts making
inappropriate jokes and becomes socially
withdrawn, neglecting personal hygiene and losing
empathy for others. His family notices that he is
unusually impulsive, making poor financial
decisions, and over time, he shows apathy toward
things he used to enjoy. Unlike Alzheimer's, his
memory remains intact, but his behavior and
personality drastically change.