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Satya Prasad

Four key factors can independently predispose individuals to delirium: vision impairments, severity of illness, cognitive impairment, and dehydration. Additional predisposing factors include advanced age, dementia, medical illnesses, infections, malnutrition, sensory impairment, surgery, and multiple medications or substances. The risk of delirium increases based on the number of predisposing factors and can be precipitated by physical restraints, malnutrition, catheters, multiple new medications, or medical complications. Certain genes may also increase vulnerability. The Confusion Assessment Method (CAM) and Memorial Delirium Assessment Scale (MDAS) are tools used to diagnose and assess the severity of delirium.

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Predisposing Factors Four factors independently predispose to delirium: vision impairments (<20/70 binocular), severity of illness, cognitive impairment, and dehydration (high ratio of blood urea to creatinine) Inouye, 2006
Predisposing Factors Elderly, especially 80 years or older Dementia, cognitive impairment, or other brain disorder Fluid and electrolyte disturbances and dehydration Other metabolic disturbance, especially elevated BUN level or hepatic insufficiency Number and severity of medical illnesses including cancer
Predisposing Factors Infections, especially urinary tract, pulmonary, and AIDS Malnutrition, low serum albumin level Cardiorespiratory failure or hypoxemia Prior stroke or other nondementia brain disorder Polypharmacy and use of analgesics, psychoactive drugs, or anticholinergics Drug abuse, alcohol or sedative dependency
Predisposing Factors Sensory impairment, especially visual Sensory overstimulation and ICU psychosis Sensory deprivation Sleep disturbance Functional impairment Fever, hypothermia Physical trauma or severe burns Fractures Male gender
Predisposing Factors Specific surgeries: Cardiac, especially open heart surgery Orthopaedic, especially femoral neck and hip fractures, bilateral knee replacements Ophthalmological, especially cataract surgery Noncardiac thoracic surgery and aortic aneurysmal repairs Transurethral resection of the prostate.
Predisposing Factors Elderly patients with dementia are five times more likely to develop delirium. Advanced age, especially older than 80 years, Neuroimaging: Many of these elderly patients predisposed to delirium have cerebral atrophy or white matter and basal ganglia ischemic changes.
Predisposing Factors The predisposing factors for delirium are ADDITIVE, As each new factor increases the risk considerably increases. The cause of delirium is multifactorial, resulting from the interaction between patient-specific predisposing factors and multiple precipitating factors. Inouye et al., 2014; Inouye and Charpentier, 1996; Laurila et al., 2008
Five specific factors that can independently precipitate delirium Use of physical restraints. malnutrition or weight loss (albumin levels less than 30 g/L) use of indwelling bladder catheters adding more than three medications within a 24-hour period Iatrogenic medical complication Inouye and Charpentier, 1996
Delirium copy [autosaved]
Delirium copy [autosaved]
Genes and Delirium Genes associated with possible pathophysiological vulnerabilities for delirium are Apolipoprotein E (APOE), Dopamine receptor genes DRD2 and DRD3, Dopamine transporter gene, SLC6A3 APOE 竜4 carriers associated with longer duration of delirium. van Munster et al., 2009, 2010
Diagnostic Scales and Criteria Diagnosis: (DSM-V; APA, 2013), criteria for delirium. The confusion assessment method (CAM): Screening and diagnosing delirium. The Delirium Rating Scale-Revised-98 (DRS-R-98): Distinguish delirium from dementia, depression, and schizophrenia. Both the CAM and the DRS-R-98 are best used in combination with a cognitive test.
DSM-V; APA, 2013 DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, 5th ed,2013. APA - American Psychiatric Association. The presence of delirium requires all the criteria to be met: Disturbance in attention and awareness Disturbance develops acutely and tends to fluctuate in severity At least one additional disturbance in cognition Disturbances are not better explained by a preexisting dementia Disturbances do not occur in the context of a severely reduced level of arousal or coma Evidence of an underlying organic cause or causes
Confusion Assessment Method (CAM) The criteria are adapted from Inouye et al. The presence of delirium requires features 1 and 2 and either 3 or 4: Acute change in mental status with a fluctuating course (feature 1) Inattention (feature 2) Disorganized thinking (feature 3) Altered level of consciousness (feature 4)
3-Minute Diagnostic Interview for Delirium Using the Confusion Assessment Method (3D-CAM).
Feature 1: Acute Change in Mental Status with a Fluctuating Course Type of Assessment Patient responses: any positive symptom report, incorrect response, lack of response, or nonsense response indicates that the feature is present. Interviewer observations: any yes indicates that the feature is present Ask whether patient has experienced the following in the past day: Being confused Thinking that he or she is not in the hospital Seeing things that are not really there Were there fluctuations in the level of consciousness? Fluctuations in attention? Fluctuations in speech or thinking? Feature 2: Inattention Ask patient to do the following: Digit span (3 digits) backward Digit span (4 digits) backward Days of the week backward Months of the year backward Did the patient have trouble keeping track of the interview? Was the patient easily distractible? Feature 3: Disorganized Thinking Ask patient to state the following: The current year The day of the week The type of place (hospital) Was the patients flow of ideas unclear or illogical? Conversation rambling or tangential? Speech unusually limited or sparse? Feature 4: Altered Level of Consciousness None Was the patient sleepy? Stuporous or comatose? Hypervigilant? The CAM algorithm requires the presence of features 1 and 2 and either 3 or 4 to diagnose delirium.
Delirium copy [autosaved]
Confusion assessment method (CAM) for the diagnosis of delirium The diagnosis of delirium requires the presence of features 1 AND 2 plus either 3 OR 4.
The Memorial Delirium Assessment Scale (MDAS): Quantify the severity of delirium in medically ill patients. It may also be useful as a diagnostic tool, generally used after the initial delirium diagnosis is made. The Neelon and Champagne (NEECHAM) Confusion Scale: used in the nursing community It combines behavioral and physiological signs of delirium NEECHAM measures acute confusion rather than delirium.
Critical care assessment tools: The confusion assessment method for ICU (CAM-ICU) Intensive care delirium screening checklist (ICDSC) Quick screening for delirium in the ICU.
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  • 2. Predisposing Factors Four factors independently predispose to delirium: vision impairments (<20/70 binocular), severity of illness, cognitive impairment, and dehydration (high ratio of blood urea to creatinine) Inouye, 2006
  • 3. Predisposing Factors Elderly, especially 80 years or older Dementia, cognitive impairment, or other brain disorder Fluid and electrolyte disturbances and dehydration Other metabolic disturbance, especially elevated BUN level or hepatic insufficiency Number and severity of medical illnesses including cancer
  • 4. Predisposing Factors Infections, especially urinary tract, pulmonary, and AIDS Malnutrition, low serum albumin level Cardiorespiratory failure or hypoxemia Prior stroke or other nondementia brain disorder Polypharmacy and use of analgesics, psychoactive drugs, or anticholinergics Drug abuse, alcohol or sedative dependency
  • 5. Predisposing Factors Sensory impairment, especially visual Sensory overstimulation and ICU psychosis Sensory deprivation Sleep disturbance Functional impairment Fever, hypothermia Physical trauma or severe burns Fractures Male gender
  • 6. Predisposing Factors Specific surgeries: Cardiac, especially open heart surgery Orthopaedic, especially femoral neck and hip fractures, bilateral knee replacements Ophthalmological, especially cataract surgery Noncardiac thoracic surgery and aortic aneurysmal repairs Transurethral resection of the prostate.
  • 7. Predisposing Factors Elderly patients with dementia are five times more likely to develop delirium. Advanced age, especially older than 80 years, Neuroimaging: Many of these elderly patients predisposed to delirium have cerebral atrophy or white matter and basal ganglia ischemic changes.
  • 8. Predisposing Factors The predisposing factors for delirium are ADDITIVE, As each new factor increases the risk considerably increases. The cause of delirium is multifactorial, resulting from the interaction between patient-specific predisposing factors and multiple precipitating factors. Inouye et al., 2014; Inouye and Charpentier, 1996; Laurila et al., 2008
  • 9. Five specific factors that can independently precipitate delirium Use of physical restraints. malnutrition or weight loss (albumin levels less than 30 g/L) use of indwelling bladder catheters adding more than three medications within a 24-hour period Iatrogenic medical complication Inouye and Charpentier, 1996
  • 12. Genes and Delirium Genes associated with possible pathophysiological vulnerabilities for delirium are Apolipoprotein E (APOE), Dopamine receptor genes DRD2 and DRD3, Dopamine transporter gene, SLC6A3 APOE 竜4 carriers associated with longer duration of delirium. van Munster et al., 2009, 2010
  • 13. Diagnostic Scales and Criteria Diagnosis: (DSM-V; APA, 2013), criteria for delirium. The confusion assessment method (CAM): Screening and diagnosing delirium. The Delirium Rating Scale-Revised-98 (DRS-R-98): Distinguish delirium from dementia, depression, and schizophrenia. Both the CAM and the DRS-R-98 are best used in combination with a cognitive test.
  • 14. DSM-V; APA, 2013 DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, 5th ed,2013. APA - American Psychiatric Association. The presence of delirium requires all the criteria to be met: Disturbance in attention and awareness Disturbance develops acutely and tends to fluctuate in severity At least one additional disturbance in cognition Disturbances are not better explained by a preexisting dementia Disturbances do not occur in the context of a severely reduced level of arousal or coma Evidence of an underlying organic cause or causes
  • 15. Confusion Assessment Method (CAM) The criteria are adapted from Inouye et al. The presence of delirium requires features 1 and 2 and either 3 or 4: Acute change in mental status with a fluctuating course (feature 1) Inattention (feature 2) Disorganized thinking (feature 3) Altered level of consciousness (feature 4)
  • 16. 3-Minute Diagnostic Interview for Delirium Using the Confusion Assessment Method (3D-CAM).
  • 17. Feature 1: Acute Change in Mental Status with a Fluctuating Course Type of Assessment Patient responses: any positive symptom report, incorrect response, lack of response, or nonsense response indicates that the feature is present. Interviewer observations: any yes indicates that the feature is present Ask whether patient has experienced the following in the past day: Being confused Thinking that he or she is not in the hospital Seeing things that are not really there Were there fluctuations in the level of consciousness? Fluctuations in attention? Fluctuations in speech or thinking? Feature 2: Inattention Ask patient to do the following: Digit span (3 digits) backward Digit span (4 digits) backward Days of the week backward Months of the year backward Did the patient have trouble keeping track of the interview? Was the patient easily distractible? Feature 3: Disorganized Thinking Ask patient to state the following: The current year The day of the week The type of place (hospital) Was the patients flow of ideas unclear or illogical? Conversation rambling or tangential? Speech unusually limited or sparse? Feature 4: Altered Level of Consciousness None Was the patient sleepy? Stuporous or comatose? Hypervigilant? The CAM algorithm requires the presence of features 1 and 2 and either 3 or 4 to diagnose delirium.
  • 19. Confusion assessment method (CAM) for the diagnosis of delirium The diagnosis of delirium requires the presence of features 1 AND 2 plus either 3 OR 4.
  • 20. The Memorial Delirium Assessment Scale (MDAS): Quantify the severity of delirium in medically ill patients. It may also be useful as a diagnostic tool, generally used after the initial delirium diagnosis is made. The Neelon and Champagne (NEECHAM) Confusion Scale: used in the nursing community It combines behavioral and physiological signs of delirium NEECHAM measures acute confusion rather than delirium.
  • 21. Critical care assessment tools: The confusion assessment method for ICU (CAM-ICU) Intensive care delirium screening checklist (ICDSC) Quick screening for delirium in the ICU.