Differential Diagnosis Delirium
D – DRUGS!!! (especial y as a medication is introduced or dose adjusted)
L – Lack of drugs (withdrawal: EtOH, opioids, benzos, SSRI/SNRI)
• Adapted from: CHAMP: Delirium in Seniors Don Scott MD, University of Chicago
R – Restraints, reduced sensory input (vision, hearing)
I – Intracranial (CVA, bleed, meningitis, post-ictal)
Diagnosis: CAM: 1+2 + (either 3 or 4)
U – Urinary retention or fecal impaction
1= Acute Onset & Fluctuating Course
M – Metabolic including hypoxia (MI, PE), uremia, ammonia, thyroid
2= Inattention ALWAYS check the MEDICATION LIST – There is a cumulative burden effect.
Any new medication or recent dose change is suspect.
Delirium versus Dementia Common Offenders: (Drug Class and Examples) Delirium Dementia 1. Psychiatric medications
a) Antidepressants (tricyclics, SSRI/SNRI)
Attention Consciousness Disordered
d) Other (cholinesterase inhibitors/memantine, lithium)
Hallucinations Often Present 2. Anti-histamines /Anticholinergics - (diphenhydramine, hydroxyzine) Invol. Movmt Often Present
-Many unrelated drugs have anticholinergic activity such as diphenhydramine, tricyclic
Risk Assessment at Admission 3. Anti-vertigo/Anti-emetics (metoclopramide, meclizine, promethazine, prochlor 4. Muscle relaxants 5. Anti-spasmodics
a) GI (Donnatal, hyoscyamine, dicyclomine)
1-2 items = Intermediate Risk → OR 2.5
6. Anti-Parkinsons medications 7. Narcotics 8. Corticosteroids Precipitating Factors During Hospitalization 9. H2 blockers- ranitidine, cimetidine 10. Anticonvulsants 11. Antibiotics – quinolones Treatment
1. Treat underlying cause/causes
1-2 items = Intermediate Risk → OR 7.1
2. Provide supportive care and prevent complications
-Fal s, aspiration, dehydration, pressure sores, iatrogenesis
3. Nonpharmacologic – FIRST LINE THERAPY Highly vulnerable patient only needs one slight insult, versus low
-Normalize environment - get rid of tethers, keep room calm and quiet, vulnerability needing a large or numerous small insults.
uninterrupted sleep (no midnight vitals), mobilization/reorientation during day,
encourage caregiver involvement/familiar objects
-Address/remove risk factors or precipitating agents
Does this patient have delirium? JAMA 2010;304(7):779-86.
4. Pharmacologic – only when needed for patient safety
Precipitating factors for delirium in hospitalized elderly persons. JAMA 1996;275:852-7.
-Agent of choice – Haloperidol(Haldol) (LOW doses to start) 0.5 mg
Delirium in Older Persons. NEJM 2006;354:1157-65.
-Atypical antipsychotics (olanzapine, risperidone – start LOW) -Benzos – agent of choice for EtOH withdrawal, otherwise AVOID
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Differential Diagnosis