Delirium
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Basics
Description
- A temporary neurocognitive complication of illness and/or medication(s), especially common in older patients, manifested by new confusion and impaired attention
- A medical emergency requiring immediate evaluation to decrease morbidity and mortality
- System(s) affected: neurologic
- Synonym(s): acute confusional state, altered mental status, organic brain syndrome, acute mental status change, encephalopathy
Epidemiology
- Predominant age: older persons
- Predominant sex: male = female
Incidence
- >50% in older intensive care unit patients
- 11–51% in postoperative patients
- 10–40% in hospitalized older patients
- 20–22% in nursing home/post–acute-care patients
- 1–2% in outpatients
- 8–17% in older ED patients
- 14% in older postacute care patients
- 18–35% in hospitalized general medicine patients
Etiology and Pathophysiology
- Multifactorial: believed to result from a decline in physiologic reserves with aging, resulting in a vulnerability to new stressors
- Disturbance in global cortical functioning. Neuropathophysiology is not clearly defined; cholinergic deficiency, dopamine excess, and neuroinflammation are leading hypotheses.
- Often interaction between predisposing and precipitating risk factors
- With more predisposing factors (i.e., frail patients), fewer precipitating factors needed to cause delirium
- If few predisposing factors (e.g., very robust patients), more precipitating factors needed to cause delirium
- Multicomponent approach addressing contributing factors can reduce incidence and complications.
Risk Factors
- Predisposing risk factors
- Advanced age: >70 years
- Preexisting cognitive impairment
- Functional impairment
- Dehydration; high blood urea nitrogen:creatinine ratio
- History of alcohol abuse
- Malnutrition
- Hearing or vision impairment
- Multiple comorbidities
- Precipitating risk factors
- Severe illness in any organ system(s)
- Medical devices (urinary catheter, restraints)
- Polypharmacy (≥5 medications)
- Specific medications, especially benzodiazepines, opioids, and anticholinergics diphenhydramine, high-dose neuroleptics
- Pain
- Any iatrogenic event
- Surgery
- Sleep deprivation
General Prevention
Follow treatment approach.
Commonly Associated Conditions
Multiple but most common are the following:
- New medicine or medicine changes
- Infections (especially lung, urine, and blood stream, but consider meningitis as well)
- Toxic metabolic (especially low sodium, elevated calcium, renal failure, and hepatic failure)
- Heart attack or stroke
- Alcohol or drug withdrawal
- Preexisting cognitive impairment increases risk.
-- To view the remaining sections of this topic, please log in or purchase a subscription --
Basics
Description
- A temporary neurocognitive complication of illness and/or medication(s), especially common in older patients, manifested by new confusion and impaired attention
- A medical emergency requiring immediate evaluation to decrease morbidity and mortality
- System(s) affected: neurologic
- Synonym(s): acute confusional state, altered mental status, organic brain syndrome, acute mental status change, encephalopathy
Epidemiology
- Predominant age: older persons
- Predominant sex: male = female
Incidence
- >50% in older intensive care unit patients
- 11–51% in postoperative patients
- 10–40% in hospitalized older patients
- 20–22% in nursing home/post–acute-care patients
- 1–2% in outpatients
- 8–17% in older ED patients
- 14% in older postacute care patients
- 18–35% in hospitalized general medicine patients
Etiology and Pathophysiology
- Multifactorial: believed to result from a decline in physiologic reserves with aging, resulting in a vulnerability to new stressors
- Disturbance in global cortical functioning. Neuropathophysiology is not clearly defined; cholinergic deficiency, dopamine excess, and neuroinflammation are leading hypotheses.
- Often interaction between predisposing and precipitating risk factors
- With more predisposing factors (i.e., frail patients), fewer precipitating factors needed to cause delirium
- If few predisposing factors (e.g., very robust patients), more precipitating factors needed to cause delirium
- Multicomponent approach addressing contributing factors can reduce incidence and complications.
Risk Factors
- Predisposing risk factors
- Advanced age: >70 years
- Preexisting cognitive impairment
- Functional impairment
- Dehydration; high blood urea nitrogen:creatinine ratio
- History of alcohol abuse
- Malnutrition
- Hearing or vision impairment
- Multiple comorbidities
- Precipitating risk factors
- Severe illness in any organ system(s)
- Medical devices (urinary catheter, restraints)
- Polypharmacy (≥5 medications)
- Specific medications, especially benzodiazepines, opioids, and anticholinergics diphenhydramine, high-dose neuroleptics
- Pain
- Any iatrogenic event
- Surgery
- Sleep deprivation
General Prevention
Follow treatment approach.
Commonly Associated Conditions
Multiple but most common are the following:
- New medicine or medicine changes
- Infections (especially lung, urine, and blood stream, but consider meningitis as well)
- Toxic metabolic (especially low sodium, elevated calcium, renal failure, and hepatic failure)
- Heart attack or stroke
- Alcohol or drug withdrawal
- Preexisting cognitive impairment increases risk.
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