JOURNAL READING : DELIRIUM IN GENERAL P R A C T I C E Resa Putra Adipurna Salva Reverentia Yurista

Advisor : Iwan Sys, MD, Psychiatrist

ORIGINAL ARTICLE

INTRODUCTION
delirium is derived from the Latin words de (from, away) and lira (track, furrow), suggesting that the state was a change from normal consciousness and behaviour.

Currently delirium is a complex neuropsychiatric syndrome that is characterized by disturbances in consciousness, orientation, memory, thought, perception, and behaviour due to one or more structural and/or physiological abnormalities directly or indirectly affecting the brain

Typically it is a potentially reversible brain dysfunction with acute onset and fluctuating course.

PREVALENCE
-0.4 per cent in subjects aged >55 yr (Folstein et al.) -Incidence to range 3-42 per cent and prevalence to range 5-44 per cent (Fann) -rate of occurrence of delirium per admission was 11-42 per cent (Shiddiqi et al)

Generally the delirium is more frequent with older age, preexisting cognitive impairment, certain medical or surgical problems (renal impairment, fracture neck of femur, etc.), and admission to the intensive care unit (ICU).

the rates of delirium increase with the increase in the mean age of the general population

NOSOLOGY
Varieties of synonyms persist in clinical practice and are used by physicians from different disciplines

terminology tends to emphasize the aetiology or setting in which delirium is encountered e.g. acute confusional state, ICU psychosis, hepatic encephalopathy, metabolic encephalopathy, toxic psychosis, acute brain failure certain terms (acute brain failure, acute organic brain syndrome) more accurately highlight the global nature and acute onset of cerebral cortical deficits in patients with delirium, though these lack specificity from other cognitive mental disorders

CLINICAL FEATURES
Delirium is characterized by a cluster of symptoms not all of which are seen in all the patients

certain symptoms occurring more frequently than others (attention deficits, sleep-awake cycle disturbance, motor activity changes) are described as the core symptoms of delirium whereas other features are more variable in presentation Additionally, according to the activity and psychomotor behaviour, three subtypes have been described - hyperactive, hypoactive and mixed

RISK FACTORS
An understanding of risk factors is important from the perspective of management and prevention

Researchers have divided the risk factors for delirium into predisposing and precipitating factors Studies have shown that the predisposing risk factors tend to have a relatively greater contribution to the development of delirium than for the precipitating factors

PATHOGENESIS
There is no clear aetiopathogenesis model for delirium. However, two hypotheses have been proposed: neurotransmitter hypothesis and inflammatory hypothesis

INSTRUMENTS FOR ASSESSMENT OF DELIRIUM

The instruments used for assessment of cognitive functions only include Mini Mental State Examination (MMSE) and Cognitive Test for Delirium (CTD) It is important to note that MMSE and CTD, being the instruments for assessment of cognitive functions only, are insufficient to distinguish delirium from dementia, and require the use of ICD-10 or DSM-IV-TR criteria for confirmation of the diagnosis MMSE can only be used in co-operative patients Compared to MMSE, CTD is useful in evaluation of a range of neuropsychological functions (orientation, comprehension, attention, vigilance and memory) and can also be used in the patients who are immobile or intubated, or lack verbal ability

DIFFERENTIAL DIAGNOSIS
The common differential diagnoses of delirium are dementia, depression and psychosis/schizophrenia

MANAGEMENT OF DELIRIUM
Adequate management of delirium : Identification of the aetiological agents factor, treatment/correction of the aetiological factor, non-pharmacological management focusing on providing optimal environment for recovery pharmacological management

PHARMACOLOGICAL TREATMENT
Based on empirical knowledge rather than well designed efficacy studies an largely consists of

antiphsycotic medication administration

HALOPERIDOL
The most commonly antipsychotic drug that used for treating delirium is haloperidol Dose range of 12 mg 24 hourly (0.250.50 mg 4 hourly for elderly), with titration to higher doses, as needed

ATYPICAL ANTIPSYCHOTIC DRUG

Risperidone Very limited randomized Olanzapine controlled trial Quentiapine Atypical antiphsycotic drug administration for treating delirium :
Started in low doses and than titrated upward Should be tapper off after 1 week symptomp free period

BENZODIAZEPINES
First line treatment for delirium related to substances use or seizure Lorazepam is preferred Short acting nature Abscence of major active metabolites Relatively predictable bioavalability when administered intra muscullary Lower doses required in : Elderly patients Respiratory compromise Hepatic compromise Receiving drugs that undergo extensive hepatic metabolism

 However delirium is often multiaetiological and a concomitant antipsychotic may be required

HOW TO PREVENT DELIRIUM ?

Properly managing the risk factor Common preventive elements :
Elimination of unnecessary medication Careful attention to hydration and nutrition Pain management using adequate and appropriate measures Sleep enhancement Early mobilisation Cognitive stimulation

PROGNOSIS
.

most cases of delirium is seen as a condition reversible in 10-12 days

Further, delirium has been shown to be associated with enduring cognitive deficits even after symptomatic recovery and with increased risk of death

THANK YOU

 Advantages of atypical antipsychotic : As effective as haloperidol but have lower incidence of side effects and required lower doses compared to conventional antipsychotic drugs Disadvantages of benzodiazepin : Worsen mental state Doses > 2mg/day (or lorazepam dose equivalent for other benzodiazepines) increased the risk of delirium in patients with cancer

Advantages of haloperidol Few active metabolite Small likelihood of sedation and hypotension Fewer extrapirAmidal syndrome Administration : oral, intramuscular, intravenous Disadvantages of haloperidol Need electrocardiogram monitor due to increased incidence of prolongation of QT interval and arrhytmias Can lead to torsades de pointes and ventricular fibrilation