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Delirium


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APPENDIX C

Unstable and High Risk Conditions

Delirium – Delirium (also known as organic brain syndrome, organic psychosis, acute confusional state, acute brain syndrome and various other names) is a common disorder of cognition and consciousness of abrupt onset. Delirium is easily overlooked and a harbinger of a poor outcome. The elderly, demented, or chronically ill are at elevated risk of delirium. The cognitive and behavioral disturbances characterizing delirium often mimic the signs and symptoms of Major Depressive Disorder (MDD), dementia, psychotic disorders, and impulse control disorders. These disturbances are generally caused by direct physiological consequences of a general medical condition, medication or substance, or due to substance intoxication or withdrawal. Often a combination of these etiologies is responsible.

Failure to recognize delirium or misdiagnosis of the same is a serious problem. First, correction of the mental status changes requires correction of the underlying medical cause. Second, the presence of delirium is a predictor of mortality and morbidity. Other consequences include a delay in the administration of appropriate therapy and increased risk for prolonged hospitalization or institutionalization. Delirium may be approached as follows:

1. Maintain Index of Suspicion

The following have been identified as risk factors for the development of delirium:

· Age greater than 65, with or without past psychiatric history (though absence of past or family psychiatric history can be quite valuable in terms of diagnosis)

· History of significant substance abuse

· Advanced general medical condition, especially if it is worsening

· Poor nutritional status

· Conditions that predispose to sensory deprivation (blindness, deafness, sleep disturbances, etc.)

· History of neurological disease or insult (dementia, traumatic brain injury, etc.)

· Heightened susceptibility to infection

· Multiple medications (especially with significant anti-muscarinic properties).

2. Assess for Core Cross-Sectional Features

These are the essential presenting features of delirium, which may be divided into disorders of consciousness, cognition (and attention), and behavior. They reflect the criteria put forth in the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

a. Disorder of consciousness

The delirious patient suffers from diminished awareness and attentiveness to his/her environment. This may be reflected in disorientation to time and/or place. Only the most seriously ill may be disoriented to person. Delirious patients are easily distracted, and are thus prone to transient shifts of attention to environmental stimuli. Finally, transient somnolence (arousable, but cannot keep train of thought) or stupor (vigorous stimulation required for arousal) may be apparent either upon presentation or by history.

b. Disorder of cognition

Memory disturbances may be readily apparent, with short-term memory being more severely affected and long-term memory being relatively prescribed (although this may not always be the case). This phenomenon may stem, from specific deficits in registration, retention and recall. These may be assessed using standardized tools such as the Mini-Mental Status Examination (MMSE).

Misidentification of unfamiliar objects as being familiar and other perceptual disturbances such as visual, gustatory, olfactory or tactile hallucinations (as opposed to auditory hallucinations characteristic of schizophrenia), as well as hypnagogic or hypnapompic hallucinations, may be present. Although delusions can be a feature of delirium, they tend not to be as fixed across time, or as systematized as though associated with intrinsic psychotic disorders. The aforementioned distractibility usually leads to problems with tasks that depend on a certain degree of sustained concentration; and may cause difficulties with problem solving.

Speech can also be affected by the patient's inability to maintain attention. Clear streams of thought cannot be maintained, resulting in fragmented, halting or incoherent speech. In tandem with memory disturbances, this can lead to a pattern of speech marked by no apparent connection from topic to topic.

c. Disorder of behavior

Combinations of the above deficits in cognition and consciousness may lead to fragmented and unpredictable behaviors, shifting between states of heightened agitation and marked quiescence (variable psychomotor activity), along with rapidly alternating emotional symptoms. Sleep disturbances are profound, often with complete reversal of the normal sleep/wake cycle, or nocturnal exacerbations of any of the previously mentioned disturbances of consciousness, cognition or behavior ("sundowning").

3. Assess for Longitudinal Features

The symptoms of delirium typically emerge abruptly, or may manifest more insidiously, erupting over hours to only a few days. Afterwards, the symptoms themselves persist in a fluctuating course, characterized by a "waxing and waning" pattern, often with brief periods of luscency. Night-time exacerbations are common. Other times, symptoms can follow a more stable course, presenting a true diagnostic challenge.

4. Clarify the Underlying Cause and Provide Appropriate Treatment. See Module A.

Severe Psychotic Symptoms – "Psychosis," in and of itself, is not a disorder. Rather, it is a symptom which may present in a variety of conditions. Psychotic patients have an impaired sense of reality, which may manifest in several ways (hallucinations, delusions, mental confusion or disorganization).

There are many causes of psychosis, including primary psychiatric illness; drug-induced psychoses (e.g., therapeutic agents, alcohol, illegal drugs); withdrawal from CNS depressants; poisoning (carbon monoxide, Belladonna alkaloids, etc.), and selected medical conditions.

Psychotic symptoms become severe when the patient's sense of reality becomes so impaired that there is potential for self-harm or harm to others. These dangerous behaviors, or the potential for such behaviors, often stem from paranoid ideations or responses to internal stimuli (e.g., auditory hallucinations). A mental health consultation or referral is almost always indicated.

Severe Depression – The clinical presentation of depressed patients is marked by considerable variation, not only in the expression of various neurovegetative symptoms themselves, but also in the magnitude of severity of these symptoms. While many mild to moderate illnesses may not necessarily present as situations mandating immediate attention, the presence of severe depressive symptoms may represent a situation entirely to the contrary—even in the absence of suicidal ideation.

It is important to first recognize that what appears to be a severely depressed patient may actually be a patient harboring an unstable organic pathology. Suspicion is raised in the setting of 1) no personal or family history of psychiatric illness; 2) discernible alteration or sudden change in consciousness or cognitive status; or 3) elderly; 4) demented; 5) post-operative; or 6) multiple medications or medical problems; or 7) metabolic abnormality.

If no organic etiology is apparent, there still remains the question of a severe and unstable depression. Specific situations which place the patient at added risk to self, even in the absence of suicidal ideation, include the following:

Severe neurovegetative disturbance in the form of anorexia/severe weight loss

Anhedonia or lethargy which has progressed to the inability to provide adequate self-care

Presence of psychotic features

Severe agitation

Refusal of medication

Catatonia

The presence of any of the aforementioned items may be an indication for mental health consultation or referral.

The Potentially Violent/Agitated Patient – Violence often emerges as a response to perceived threat or from marked frustration caused by the inability to meet goals by nonviolent means. The specific factors that contribute to violent behavior include psychiatric, medical, environmental, and situational/social. Often it is a combination of factors that precipitates and aggravates the potential for violence. Violence may quickly escalate to frank agitation or the carrying out of violent impulses. Whatever the cause, the following situations may serve as warning signs pointing towards a threat of violence:

Ideation and/or intent to harm others

Past history of violent behaviors

Severely agitated or hostile

Actively psychotic

Immediate attention and intervention may be required in order to stave off the potential for escalation of agitation or violent impulses. The assessment of the potentially violent patient has three primary tasks:

assessing the cause, assessing the intent, and establishing control of an acute situation.

1. Assessing the Cause

Though the causes of violent behaviors are numerous, they can be grossly subdivided into three main categories. This classification scheme suggests not only a pathway for further evaluation, but also suggests which forms of treatment may be more effective. The categories are: organic mental disorders, psychotic disorders and non-psychotic, non-organic disorders.

· Organic mental disorders

The differential diagnosis under this section closely mirrors that of delirium. The primary culprits include:

a. Infections (systemic or Central Nervous System [CNS])

b. Substance withdrawal (CNS depressants)

c. Substance intoxication (alcohol and other CNS depressants, phencyclidine and other CNS stimulants, hallucinogens, inhalants, anticholinergic medications, steroids)

d. Hypoxia (any cause)

e. Hypertension

f. Hypoglycemia

g. Hypo- or hyper-natremia

h. Acid-base disturbances

i. Hypo- or hyper-thyroidism

j. Severe hepatic or renal disease

k. CNS pathologies (seizures, tumors or other space-occupying lesions, encephalitis, meningitis, intracranial bleed, dementing illness, NPH, MS, CVA/infarct)

l. Traumatic brain injury

m. Deficiency state (B12, folate)

n. Toxin exposure (heavy metals, insecticides)

o. Drugs that cause delirium

· Psychotic disorders

In assessing the potentially violent patient, it is most useful to concentrate on the presence or absence of delusions (especially paranoid delusions), hallucinations (especially command-type hallucinations), catatonic excitement, mania (with or without psychotic features); or major depressive disorder with psychotic features.

· Non-psychotic, non-organic disorders

These include disorders of impulse control, Axis II pathologies and violent behavior that may be present in various syndromes of mental retardation.

2.

3. Assessing the Intent

Assessment of violent intent is quite challenging unless it is actively endorsed by the patient via direct questioning. Most studies concerned with the prediction of violent behavior have focused on demographic aspects and risk factor identification. Such studies may accurately reflect violent behaviors in the particular groups studied; however, their usefulness in predicting an individual patient's behaviors is less so. Some basic risk factors for violence are listed below:

· Threat is well-planned

· Means to harm others are readily available /li>

· Past history of violence to others, especially in the immediate past

· Past history of dangerous impulsive behaviors

· History of having suffered from child abuse

· Alcohol or other substance abuse

· Psychosis

· Escalating level of agitation

4. Establishing Control of an Acute Situation

See Module A.

Threat To Self/Suicidality – See Module A.

NOTE: This Appendix has been adapted from the Veterans Health Administration (VHA)/Department of Defense (DoD) Clinical Practice Guideline for the Management of Major Depressive Disorder in Adults. Version 2.0, February 2000. Available at URL http://www.oqp.med.va.gov/cpg/cpg.htm

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