This is a brief overview of delirium originally given as a talk for nurse in Kettering, UK, 2007.

1. Delirium & Confusion

2. Confusion over terminology
• “Confusion”
– AKA Disorientation
– Incoherence
– Clouding of consciousness
– Delirium

3. Delirium: Definition
• de lira “to wander”
• clinical syndrome (not disease) characterised by
?

4. Scope of the Problem
• 10-15% delirious on admission (Inouye 1997, Lipowski 1987)
• 5-40% incident delirium in hospital (Francis 1992)
• Settings
– 11-43% post-operatively (Bryson 2006)
– 70-87% in the ICU (Pisani 2006)
– > 70% in terminal CA (Massie 1987)

5. Delirium: Outcomes - Duration
• More persistent than previously realised
• Up to one week in 60%
• two weeks in 20%
• four weeks in 15%
• more than four weeks in 5%
• Delirium still present at 6 months
– O'Keeffe S The prognostic significance of delirium in older hospital patients J of
the Am Geriatr Soc 1997;45(2):174-8

6. Delirium: Outcomes Mortality
• Delirium in hospital is associated with mortality rates
of 25 – 33%
• Most studies report higher mortality after discharge
eg 39% vs 23% at two years
– Francis J Prognosis after hospital discharge of older medical patients with
delirium. J Am Geriatr Soc 1992;40(6):601-6
• Hazard ratio of 2.11 at 1 year adjusted for
comorbidity, dementia and severity of illness
– McCusker et al Delirium predicts 12 month mortality. Arch Intern Med.
2002;162:457-463

7. Clinical Presentation

8. Delirium: Clinical Features
• Inattention (95%)
• Disorientation
• Short term memory impairment
• Thinking is disordered
• Speech rambling and incoherent
• Delusions, misperceptions and visual
hallucinations
• Distress, anxiety

9. Delirium: Clinical Features
• Hyperactive delirium
– Repetitive behaviours e.g. plucking at sheets, wandering,
verbal and physical aggression
• Hypoactive delirium
– quiet, withdrawn patient, often mistaken for depression
• Mixed pattern

10. Lethargy
Agitation
Day Night
Night
Day
Day DayNight Night
PRN
Course of Delirium

11. ICD 10 definition
Impairment in consciousness & attention
Global cognitive impairment
Psychomotor disturbance
Sleep-wake cycle disturbance
Emotional disturbance

12. DSM IV definition
Disturbed consciousness
Disturbed attention
Disturbed cognition
Acute onset
Fluctuating symptoms

13. A Case That Breaks the Rules
• Ms EM, a 27 y/o with Hodgkins, two months post-natal
• EM experienced disturbed sleep-wake cycle, disorientation, distractibility,
and a sub-acute onset of confusion over seven days. There was also mild
daytime somnolence but no changes in consciousness, no psychotic
symptoms or perceptual disturbance, and no convincing fluctuations. She
was not unduly agitated or over-aroused.
• She scored 6 out of 10 on the clock-drawing test (CDT), and 22/30 on the
mini-mental state examination (MMSE).
• On the Delirium Rating Scale she scored 11 out of a possible 32.
Functionally, she stopped working and driving, and required assistance
with everyday household tasks.
• At one year the symptoms had not changed.

14. QualifyingQualifyingNoCausative agent
EssentialQualifyingNoRapid onset and fluctuation of symptoms
Not requiredEssentialYesEmotional disturbance
Not requiredQualifyingYesImpairment of abstract thinking or comprehension
QualifyingQualifyingYesMemory impairment
QualifyingQualifyingYesDisorientation
Not requiredQualifyingNoIncreased or decreased motor activity
Not requiredQualifyingYesDisturbance of sleep-wake cycle
QualifyingNot requiredYesDisorganized thinking/incoherent speech
QualifyingQualifyingNoPerceptual disturbances
EssentialEssentialYesImpairment of attention
QualifyingEssentialNoClouding/disturbance of consciousness
DSM-IVICD-10This CaseCriteria

15. Laurila (2003) 425 patients hospital & nursing home
ICD 10
DSM IV
81 18
25

16. Prodromal Symptoms
• Prospective & descriptive observational study
• 6 hours before meeting DSM IV criteria
• Behavioural symptoms noticed
• Urgent calls for attention
• Anxiety
• Disorientation
• Decreased psychomotor activity
Other literature
– Altered sleep pattern
– Fatigue
Sorensen & Wickbald (2004), J of Clin Nursing, 13

17. Risk Factors and Aetiology

18. Risk factors for incident delirium
Predisposing RR
• Vision imp. 3.5
• Severe illness 3.5
• Dementia 2.8
• Dehydration 2.0
Precipitating RR
• Restraints 4.4
• Malnutrition 4.0
• >3 new med.s 2.9
• Bladder catheter 2.4
• Iatrogenic event 1.9
Inouye et al,Ann Med 2000;32:257-263

19. Mechanisms
• Nearly all speculative
• Metabolic deficits difficult to measure

20. Detection

21. Delirium: Detection
• Delirium often missed
• 32 – 67% of delirious patients are not diagnosed
• Cognitive assessment should be standard
– MMSE or AMTS
• Serial testing to monitor progress and to detect
delirium arising during an admission
• Mental status = a “vital sign”

22. Educational intervention => recognition
Rockwood et al (1994)
• Simple educational intervention at monthly
grand ward
• Diagnosed 3% pre intervention (187 pts)
• Diagnosed 9% post intervention (247 pts)
• Frequent comments on various aspects of
mental state (15.6% Vs. 8.5%)
Rockwood et al (1994) J of Am Ger Soc, 42

23. Delirium: Differential Diagnosis
Meagher, D J Delirium BMJ 2001; 322: 144 -149
Delirium Dementia Depression
Onset Acute Insidious Variable
Course Fluctuating Steadily progressive Diurnal variation
Consciousness and
orientation
Clouded;
disoriented
Clear until late
stages
Generally
unimpaired
Attention and
memory
Poor short term
memory; inattention
Poor short term
memory without
marked inattention
Poor attention but
memory intact
Psychosis present? Common (psychotic
ideas fleeting,
simple content)
Less common Occurs in small
number (psychotic
symptoms complex
and mood
congruent)
EEG Abnormal in 80-
90%; generalised
diffuse slowing in
80%
Abnormal in 80-
90%; generalised
diffuse slowing in
80%
Generally normal

24. Delirium
Dementia

25. Scales (assisted detection)

26. Scales
• Delirium Rating Scale Revised 98 (DRS-R-98)
• Brief Psychiatric rating Scale (BPRS)
• Mini Mental State Examination (MMSE)
• Clinical Global Improvement (CGI)
• Medical notes, prescription charts and investigations
• Actimeter

27. • Operationalized DSM-III criteria
1. Acute Onset and
2. Fluctuating course and
3. Inattention, Plus:
• Disorganized speech or
• Altered level of consciousness
- Inouye SK, Ann Int Med 1990
Confusion Assessment Method (CAM)

28. Diagnostic Testing: Tools
Sensitivity Specificity
• CAM* .46-.92 .90.92
• Delirium Rating Scale .82-.94 .82-.94
• Clock draw+ .87 .93
• MMSE (24 cutoff) .52-.87 .76-.82
• Digit span test .34 .90
*validated for delirium & capable of distinguishing delirium from dementia

29. The Clock Drawing Test
12
6
39
10
11 1
2
4
57
8
•Used extensively in assessment of cognitive
function, especially as a screen for dementia
•Administration is quick, easy and non-threatening
•Several studies assessing its validity as a screen
for delirium with conflicting results
•Multiple scoring methods, >12 reported in the
literature
J Geriatr Psychiatry Neurol 2005;18:129-133
Int J Geriatr Psychiatry 2000;15:548-561
Draw a clock face. Set the time at 10 past 11.

30. The Clock Drawing Interpretation Scale
1. There is an attempt to indicate a time in any way.
2. All marks or items can be classified as either part of a closure figure, a hand, or a symbol for clock
numbers.
3. There is a totally closed figure without gaps (closure figure).
4. A “2” is present and is pointed out in some way for the time.
5. Most symbols are distributed as a circle without major gaps.
6. Three or more clock quadrants have one or more appropriate numbers:12-3, 3-6 etc.
7. Most symbols are ordered in a clockwise or rightward direction.
8. All symbols are totally within a closure figure.
9. An “11” is present and is pointed out in some way for time.
10. All numbers 1-12 are indicated.
11. There are no repeated or duplicated number symbols.
12. There are no substitutions for Arabic or Roman numerals.
13. The numbers do not go beyond the number 12.
14. All symbols lie about equally adjacent to a closure figure edge.
15. Seven or more of the same symbol type are ordered sequentially.
16. All hands radiate from the direction of a closure figure center.
17. One hand is visibly longer than another hand.
18. There are exactly two distinct and separable hands.
19. All hands are totally within a closure figure.
20. There is an attempt to indicate a time with one or more hands.
(Score “1” per Item)
Score Only if Symbols for Clock Numbers are Present:
Score Only if One or More Hands are Present:
J Am Geriatr Soc 1992;40:1095-1099

31. Simple screen (Henderson Data)
Clock drawing test
sensitivity 0.92 (0.86 – 0.98)
specificity 0.73 (0.64 – 0.83)
PPV 0.61
NPV 0.95
Kappa = 0.57 z = 5.43 p < 0.001

32. 0.000.250.500.751.00
Sensitivity
0.00 0.25 0.50 0.75 1.00
1 - Specificity
Area under ROC curve = 0.8464
ROC curve for Clock Drawing Test using AMTS as gold standard

33. Management

34. Basics
0. Assessment, investigate, document
1. Treat cause
2. Supportive care
• Maintain proper nutrition, hydration and safety (prevention aspiration,
ducubitus ulcers, falls etc)
3. Pharmacologic
• Antipsychotic medications (haloperidol, respiridone, olanzapine etc.)
• Benzodiazepines do not play a role (except in alcohol withdrawl related
delirium)
4. Nonpharmacologic
• Interpersonal contact (reorientation)
• Environmental (clocks, windows, provide hearing aids, glasses, minimizing
room changes etc.)
Moore & Jefferson: Handbook of Medical Psychiatry, 2nd ed., Copyright © 2004 Mosby Inc
Am J Geriatr Psychiatry 2004;12;7-21

35. Delirium: Investigation
• Routine
• FBP
• U&E
• Glucose
• Calcium
• Liver function tests
• Cardiac enzymes
• Urinalysis and MSU
• O2 saturation
• CXR
• Consider
• ECG
• TFT
• Arterial blood gases
• B12 and folate
• CT brain
• EEG

36. Haloperidol
• Rosen H, (1979) Haloperidol Vs Thioridazine
• Tsuang M, (1971) Haloperidol Vs Thioridazine
• Thomas et al (1992) Haloperidol Vs Droperidol
• Brietbart et al (1996) Haloperidol, CPZ & Lorazepam

37. Delirium: Non Pharmacological Mx
• Correct sensory deficits (glasses and hearing aids)
• Communication, simple instructions, avoid jargo
• Re orientation (calendars, clocks, schedules)
• A quiet, stable environment (Minimise room and
staff changes)

38. Delirium: Non Pharmacological Tips
• Avoid sleep disruption
• Encourage mobility and self care
• Avoid restraints and bed rails
• Involve family where possible
• Meaningful personal items
• A view to the outside

40. Prevention

41. Non Pharmacological Mx: Does it work?
• Cole et al found 227 with incident or prevalent
delirium amongst 1925 patients in 5 general medical
units
• Randomised to usual care or geriatrician and nurse
consultation & follow up
• No significant differences in LOS, time to
improvement, discharge, mortality!!
• Cole MG et al. Systematic detection and multidisciplinary care of delirium in older
medical inpatients: a randomized trial. CMAJ. 2002; 167(7):753-9.

42. Delirium: Prevention
• Prospective study involving 852 patients with 426
matched pairs compared usual care of elderly
general medical patients with those receiving
interventions
– Incidence of delirium lower in intervention vs usual
care group (9.9% vs 15%)
– Total days of delirium (105 vs 160)
– Number of episodes of delirium (62 vs 90)
– No difference in severity of delirium or recurrence
rates
– Major effect of interventions was to prevent the
primary episode of delirium
Inouye et al N Engl Med 1999;340:669-76

43. Delirium: Prevention
Hip Fracture
• Marcantonio et al. Pre-op and daily post-op geriatric
review 126 elderly patients (RCT)
• Oxygen, fluid/electrolytes
• pain, medication review/reduction
• bowel and bladder function
• nutrition, early mobilisation and rehabilitation
• prevent/detect/treat post op complications
• environmental stimuli
• treat delirium

44. • 126 patients > 65 y/o for hip fracture repair
• Pre-op and daily post-op geriatric review or
usual care
– Delirium: 32% vs 50% (NNT = 6) RR 0.6
– Severe delirium: 12% vs 29% (NNT = 6) RR0.4
– Those without dementia benefited most
– Marcantonio et al. Reducing Delirium after Hip Fracture J Am Geriatr
Soc 2001;49: 516-22
Delirium: Prevention Hip Fracture

45. Extras

46. Mental Capacity Act (2005)
• Premise: everyone can make their own decisions.
• Give the person all the support they can to help them
make decisions.
• No-one should be stopped from making a decision
just because someone else thinks it is wrong or bad.
• Anytime someone does something or decides for
someone who lacks capacity, it must be in the
person’s best interests
• When they do something or decide something for
another person, they must try to limit your own
freedom and rights as little as possible.

47. Advance (directives) Decisions
• An advance decision is when someone who has mental
capacity decides that they do not want a particular type of
treatment if they lack capacity in the future.
• A doctor must respect this decision.
• If the advance decision says no to treatment which may help
keep you alive, it must say this clearly and be signed by you.
Another person can sign an advance decision for you but
only if you agree and you can see them sign it.
• You are free to make an advance decision if you want to, but
no one should force you to make it.

49. Zorn SH et al. Interactive Monoaminergic Brain Disorders. 1999:377-393.
Schmidt AW et al. Eur J Pharmacol.2001;425:197-201.
Quetiapine
M1
5-
HT2AD2
5-
HT2C
5-
HT1A
α1
H1
Risperidone
D2
α1
5-
HT2A
5-
HT2C
H1
Olanzapine
M1
H1 5-
HT2C
5-
HT2A
D2
α1
Ziprasidone
D2
5-HT1D
5-
HT2C
5-HT1A
5-
HT2A
α1
H1
Clozapine
5-
HT2C
M1
5-
HT2A
H1 α1
D2
Pharmacology Of Atypical Antipsychotics

50. • Disturbance of Consciousness
– Reduced clarity of awareness of the environment
– Reduced ability to focus, sustain, or shift attention.
• A change in cognition
– Memory deficit
– Disorientation
– Language disturbance
• Perceptual disturbance
– Illusions
– Visual Hallucinations
– Auditory hallucinations
DSMIV Delirium Symptoms

51. • Fluctuating clinical picture
• Disturbance caused by underlying disorder.
• Confirmed by investigations & physical
examination
• Sleep disturbance
• Disturbance of psychomotor activity
DSMIV Delirium Symptoms 2