Cases Of Delirium Research Articles

Emergence Delirium: A Nursing Perspective

Emergence delirium is a condition that can affect all segments of the postoperative population, but is seen most often in pediatric and older adult patients. Most cases of emergence delirium resolve quickly and without incident; however, severe episodes may lead to increased incidence of injury to both patients and staff members and increased costs. To minimize the incidence of emergence delirium and treat it when it occurs, perioperative nurses must be aware of the risk factors that contribute to this condition, including the patient's age, type of anesthesia, anxiety level, level of postoperative pain, and preexisting medical conditions.

Clinical observations of postoperative delirium after surgery for oral carcinoma

The aim of the present study was to clarify the clinical characteristics of postoperative delirium and to determine appropriate postoperative management for its prevention. The authors analysed 132 cases of primary surgery for oral carcinoma and observed 24 (18%) cases of postoperative delirium. Univariate analysis revealed that significant risk factors for postoperative delirium were older age, male gender, extensive surgery and morphine pain control. Logistic regression analysis showed that older age and male gender were significant risk factors for postoperative delirium, while patient-controlled analgesia with fentanyl was effective for prevention of postoperative delirium. There was a trend for postoperative delirium to be associated with extensive surgery. In those who had delirium, blood tests revealed that alkaline phosphatase, total protein, sodium, chlorine, red blood cell count, haemoglobin and haematocrit were significantly diminished after surgery. These results indicate that general condition is closely related to the onset of postoperative delirium, and suggest that appropriate postoperative management can reduce the incidence of this complication.

Levofloxacin-induced delirium

An 83-year-old man was admitted for right lower lobe pneumonia which did not improve after a 5-day outpatient treatment with amoxicillin/clavulinate and clarithromycin. An empiric treatment with levofloxacin was started with a significant improvement after 24 h of this treatment. On the third day of hospitalization, delirium developed, while the patient was afebrile and with normal blood oxygenation. Treatment with levofloxacin was stopped, and a complete resolution of the patient's delirium was observed 2 days later. To the best of our knowledge, this is the third case of levofloxacin-induced delirium described in the medical literature.

Delirium in the Intensive Care Unit: Medications as Risk Factors

Delirium in the Intensive Care Unit: Medications as Risk Factors

Palliating delirium in patients with cancer

Delirium is a frequent complication in oncology. Its definition as a disorder of consciousness, attention, and cognition is useful to elaborate a rational framework of its pathophysiology and to interpret the role of different aetiological factors and therapeutic interventions. Many aetiologies and an interaction between risk and predisposing factors have been shown to contribute to most cases of delirium. A screening of potential aetiologies is always mandatory to benefit reversible cases. The palliative treatment of symptoms of delirium includes non-pharmacological, environmental, and preventive interventions and the use of haloperidol. If haloperidol fails to control delirium, sedation with other drugs can be necessary. Specific attention to the qualitative aspects of care and to the effect of delirium on family members should be given in the overall assessment of the patient in his or her cancer trajectory.

Use of Thiamine in the Treatment of Post-electroconvulsive Therapy Delirium

Electroconvulsive therapy (ECT) is a safe and effective treatment for refractory depression, mania, and psychosis [8] [10]. The common adverse effects of ECT are cognitive impairments such as retrograde amnesia and delirium. However, these conditions are usually transient and have a self-limiting course [3]. In elderly patients, the postictal state (post-ECT delirium) is occasionally prolonged and often accompanied by disorientation and agitation. Post-ECT delirium is troublesome and may necessitate discontinuation or reduction of the course of ECT in some patients. Various pharmacotherapies with benzodiazepines or antipsychosis drugs are prescribed to prevent post-ECT delirium [1]. However, the beneficial effects of these agents have been controversial. Linton et al. [6] reported major depression and post-ECT delirium in 3 elderly patients, and they were the first to describe the successful treatment of post-ECT delirium with thiamine. To date, no other report has been published in this field of literature. We report a case of severe post-ECT delirium that presented during treatment for delusional depression and the dramatic beneficial effects of thiamine in treating it.

VALPROATE-INDUCED DELIRIUM IN A DEMENTED PATIENT

In this study we report a case of valproate-induced delirium in a patient affected with Alzheimer's disease (AD). A 75-year-old woman with AD presented moderate cognitive impairment associated to behavioral disorders, characterized by aggression, agitation, severe insomnia. She was treated with galantamine, promazine, acetylsalicylic acid and pantoprazole. Since behavioral disorders worsened more and more, home neurological consultation was asked. The neurologist prescribed a mood stabilizer, sodium valproate 500 mg daily for the first week and then, twice a day and stopped promazine. After an apparent initial benefit, about 16 days later, patient suddenly developed hyperactive delirium. It was characterized by worsening of insomnia and agitation, severe confusion, delusions, visual hallucinations alternated to sedation. She became progressively unable to walk and completely dependent in daily living activities. An urgent geriatric consultation was performed at patient's home; physical examination showed mild dehydration, normal blood pressure. Oxygen saturation and electrocardiogram were normal. Sodium valproate was immediately stopped and rehydration was performed. The patient was admitted to a Geriatric Unit, where organic and metabolic damages were excluded. During the hospital stay the patient was agitated, aggressive, confused; intramuscular haloperidol 5 mg and saline intravenous infusion 1500 cc daily were performed, they were partly successful. Three days after she was discharged and continued treatment with oral haloperidol 5 mg daily. One week later the patient recovered and she is at present healthy. This is a case report of valproate-induced delirium. The Naranjo scale scored 7, classifying this drug-related event as probable. The present case report suggests the need for minimizing the use of psychoactive drugs in elderly demented patients, whether possible; age-related changes in pharmacokinetics and pharmacodynamics suggest the opportunity of a careful evaluation and a slow titration of treatments in these patients.

Delirium in the Final Weeks of Terminally Ill Cancer Patients

Backgrounds: In terminally ill cancer patients, delirium must be considered to be important clinically and for the quality of life. We reviewed cases of delirium in hospitalized cancer patients with the aim to recognize and treat delirium. Methods: We reviewed retrospectively the medical records of patients admitted with terminal cancer from April 2003 to April 2004 in the department of family medicine, National Health Insurance Corporation Ilsan Hospital. A total of 71 patients were evaluated with age, sex, oncological diagnosis, metastases, morphine (oral morphine equivalents/day, OME) use and amount, sedatives use, duration from delirium to death, and laboratory fi ndings. Analysis was conducted to fi nd the characteristics of delirium patients and to quantify the relationship between delirium and predicting factors. Results: Among 71 cases, those patients who developed delirium were 41 (57.7%). Among them, gastric cancer was the most common diagnosis with 10 patients (24.4%), followed by colon and lung cancers (9: 22%, 5: 12.2%). The patients receiving sedatives or morphines were 24 (58.5%) and 28 (68.3%), respectively. The mean amount of morphine was 168.6 ± 125.5 mg OME/day. Hyperbilirubinemia (4.2 ± 9.2 mg/dL) and hyponatremia (132.5 ± 4.5 mM/L) were found. Not only bone metastasis and the use of morphine or sedatives but serum Na were signifi cant (P = 0.047; P < 0.001; P = 0.069; P = 0.029). By logistic regression analyses, the occurrence of delirium was increased with decreased serum Na (odds ratio [95% CI] 0.798 [0.649-0.981]) and increased use of sedatives (5.955 [1.080-32.835]). Conclusion: In terminally ill cancer patients, the risk factors of delirium were bone metastasis, the use of morphine or sedatives, and serum Na level. Among these, the use of sedatives and serum Na level were independent risk factors.

P01-65 Children of Bacchus - withdrawal in the ER

Through the ages, Portugal's History, geography, industry and mysticism are intertwined with viniculture. Legends proclaim Lusus the founding father of its inhabitants, who answer to this day to the designation of "Lusos". Lusus was said to be a companion of Bacchus, the Roman God of Wine. Portugal was the 7th major alcohol consumer, according to data by the world Drink Trends 2005. Facing these numbers, it is fairly understood the morbidity and lethality potential of multi-organic diseases, neurologic entities, accidents, suicides, and familial disfunction. Alcoholic Delirium may be caused by alcohol withdrawal, or by a sudden increase in consumption, or phenomena where tolerance to alcohol is diminished. These complex states are affluent in symptomatology, which can evolve to critical life threatening stages.Objective:The authors’ aim is to present a clinical case of Delirium by alcoholic withdrawal.Methods:The authors undertake a revision of this topic in the literature and clinical files review.Conclusions:Delirium is not uncommon in Portuguese emergency rooms, though often misdiagnosed. The knowledge tools should be shared by other specialities besides Psychiatry or Liaison Mental Health for treatment may be life-saving. After crisis, the treatment should proceed, based on maintaining abstinence by medication and therapy.

Gamma-hydroxybutyrate withdrawal syndrome: dangerous but not well-known

Gamma-hydroxybutyrate (GHB) is an endogenous inhibitory neurotransmitter and anesthetic agent that is being abused as a ‘club drug.’ Withdrawal symptoms after cessation of GHB use are common and depend on the intensity of use. However, GHB withdrawal syndrome and delirium are unfamiliar to most psychiatrists, probably due to the fact that neither textbooks nor guidelines cover the subject. The GHB withdrawal syndrome may have a fulminant course that progresses to delirium. In those severe cases, admission to a general hospital and involvement of a psychiatrist become necessary. We present two cases of severe GHB withdrawal delirium, provide an overview of the literature and conclude with treatment recommendations.

Dexmedetomidine Infusion as Adjunctive Therapy to Benzodiazepines for Acute Alcohol Withdrawal

To report a case of alcohol withdrawal and delirium tremens successfully treated with adjunctive dexmedetomidine. A 30-year-old man with a history of alcohol abuse was admitted to the general medical unit because of altered mental status and agitation. He was initially treated for alcohol withdrawal with benzodiazepines; his condition then deteriorated and he was transferred to the intensive care unit. Because of the patient's poor response to benzodiazepines (oxazepam and lorazepam, with midazolam the last one used), intravenous dexmedetomidine was started at an initial dose of 0.2 microg/kg/h and titrated to 0.7 microg/kg/h to the patient's comfort. Midazolam was subsequently tapered to discontinuation due to excessive sedation. In the intensive care unit, the patient's symptoms remained controlled with use of dexmedetomidine alone. He remained in the intensive care unit for 40 hours; dexmedetomidine was then tapered to discontinuation and the patient was transferred back to the general medical unit on oral oxazepam and thiamine, which had been started in the emergency department. He was discharged after 5 days. A review of the PubMed database (1989-2007) failed to identify any other instances of dexmedetomidine having been used as the principal agent to treat alcohol withdrawal. The use of sedative to treat delirium tremens is well documented, with benzodiazepines being the agents of choice. The clinical utility of benzodiazepines is limited by their stimulation of the gamma-aminobutyric acid receptors, an effect not shared by dexmedetomidine, a central alpha(2)-receptor agonist that induces a state of cooperative sedation and does not suppress respiratory drive. In patients with delirium tremens, dexmedetomidine should be considered as an option for primary treatment. This case illustrates the need for further studies to investigate other potential uses for dexmedetomidine.

Delirium after elective surgery among elderly patients taking statins

Postoperative delirium after elective surgery is frequent and potentially serious. We sought to determine whether the use of statin medications was associated with a higher risk of postoperative delirium than other medications that do not alter microvascular autoregulation. We conducted a retrospective cohort analysis of 284 158 consecutive patients in Ontario aged 65 years and older who were admitted for elective surgery. We identified exposure to statins from outpatient pharmacy records before admission. We identified delirium by examining hospital records after surgery. About 7% (n = 19 501) of the patients were taking statins. Overall, 3195 patients experienced postoperative delirium; the rate was significantly higher among patients taking statins (14 per 1000) than among those not taking statins (11 per 1000) (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.15-1.47, p < 0.001). The increased risk of postoperative delirium persisted after we adjusted for multiple demographic, medical and surgical factors (OR 1.28, 95% CI 1.12-1.46) and exceeded the increased risk of delirium associated with prolonging surgery by 30 minutes (OR 1.20, 95% CI 1.19-1.21). The relative risk associated with statin use was somewhat higher among patients who had noncardiac surgery than among those who had cardiac surgery (adjusted OR 1.33, 95% CI 1.16-1.53), and extended to more complicated cases of delirium. We did not observe an increased risk of delirium with 20 other cardiac or noncardiac medications. The use of statins is associated with an increased risk of postoperative delirium among elderly patients undergoing elective surgery.

Differing management of people with advanced cancer and delirium by four sub-specialties

Introduction: Delirium in advanced cancer is prevalent, with limited prospective data to guide management. The aim was to survey current practice of specialists using two contrasting cases of delirium in cancer. Methods: A questionnaire was designed to identify investigations and treatment used, in relation to two cases. Results: Overall response rate (n = 270) was 30%. Place of care: Only 35% of medical oncologists would consider care at home for a patient with reversible delirium compared with 66% of other specialists. Investigations: 85% specialists would order basic bloods, however, medical oncologists were more likely to use oxygen saturation and head computed tomography, psychogeriatricians more likely to order thyroid function and palliative medicine specialists less likely to order chest X-ray and urine culture. Greater than 40% of specialists would do no investigations for terminal delirium. Treatment: Medical oncologists use more pre-emptive therapies and more likely to use a benzodiazepine as agent of choice, and Palliative medicine specialists used significantly more neuroleptics to treat hypoactive symptoms of delirium. Discussion: The survey emphasise significant areas of variability in the management of delirium in advanced cancer. Furthermore, evidence to guide management in ways that draw on the strengths and knowledge of each specialty is urgently needed.

Motor Symptoms in 100 Patients With Delirium Versus Control Subjects: Comparison of Subtyping Methods

Different motor presentations of delirium may represent clinically meaningful subtypes. Authors sought to evaluate delirium phenomena. They used three non-validated delirium psychomotor subtype schemas, applied to a palliative-care population. Their unique items were merged to comprise a 30-item Delirium Motor Checklist (DMC) used to collect data, rate each schema, and determine subtype frequencies in 100 consecutive DSM-IV delirium patients and 52 medically-matched control subjects without delirium. The Delirium Rating Scale-Revised-98 (DRS-R98) assessed delirium severity, and subtype categorization using its two motor items was compared with the scale that used the psychomotor schema. In delirium, motor disturbance was present in 100% by DMC versus 92% by DRS-R98 motor items; the DMC motor items also significantly distinguished delirium from control subjects. Motor subtype classification (hyperactive, hypoactive, mixed, and none) varied among the four methods, with low concordance across all four methods and 76% concordance for pairwise comparisons. The DRS-R-98 identified the most hypoactive delirium cases. Motor disturbances are common in delirium, although whether they represent clinical subtypes is confounded by methodological issues. New motor subtyping methods are needed that are validated in other medical populations, use matched control subjects, and have higher sensitivity and specificity for pure motor features.

A New Data-Based Motor Subtype Schema for Delirium

A New Data-Based Motor Subtype Schema for Delirium

Does femoral nerve analgesia impact the development of postoperative delirium in the elderly? A retrospective investigation

Summary Background The potential effects of femoral nerve analgesia on postoperative delirium and length of stay remains poorly investigated. After detecting several cases of delirium in postoperative patients, we sought to find out if femoral nerve analgesia would prove superior in the prevention of postoperative delirium when compared to a conventional analgesia regimen. Methods Ninety-nine (99) patients were retrospectively investigated for delirium following hip fracture repair in 1 year (October 2004–October 2005). Patients were divided in two groups: Group 1 (n = 49) received patient-controlled femoral nerve analgesia (PCAF), Group 2 (n = 50) were treated with intravenous analgesia. All patients were studied for the following variables: age, gender, previous dementia, length of hospitalisation, blood transfusion, haemoglobin level at discharge, delirium, respiratory failure or oxygen therapy, heart failure or acute coronary disease, renal failure, stroke, rescue opioid analgesia, sitting and walking times, patients discharge to rehabilitation centre and patients discharge without walking recovery. Results Patients in Group 1 showed significantly less occurrence of postoperative delirium than those treated with conventional analgesia (8.2% and 42%, respectively). Patients in PCAF group did not receive any morphine rescue medication in contrast to 28% of those of Group 2 (p Conclusions The incidence of postoperative delirium was lower in the PCAF group. The PCAF technique in hip fracture repair improves the quality of postoperative analgesia, without needing rescue opioid analgesia.

Memantine-Induced Myoclonus and Delirium Exacerbated by Trimethoprim

To report a case of myoclonus and delirium seen in a patient taking a combination of memantine and trimethoprim. A 78-year-old woman was admitted to the medical center in October 2007 with rapid deterioration of Alzheimer's dementia and progressive myoclonus. In 2003, donepezil 5 mg/day had been initiated and her disease slowly progressed. In 2006, memantine 10 mg twice daily was added. Myoclonic activity and delirium were noted in 2007 when a urinary tract infection (UTI) was treated with double-strength trimethoprim/sulfamethoxazole (TMP/SMX 160 mg/800 mg). After discontinuation of TMP/SMX, the patient's condition returned to baseline level. Several weeks later, trimethoprim 100 mg daily was added for UTI prophylaxis. Within weeks, spontaneous generalized myoclonic activity resumed to the extent that the patient was unable to walk. She became increasingly delirious. A week before admission, levodopa/carbidopa 250 mg/100 mg was added for presumptive restless legs syndrome and the patient became extremely delirious and combative, requiring hospitalization. Because of the striking similarity of dose-related toxicities reported with amantadine, a slightly different aminoadamantane, memantine was withheld. Trimethoprim was discontinued due to a likely interaction with memantine. Donepezil and famotidine were withheld due to questions of therapeutic necessity. After 3 days, the myoclonus had completely resolved and the patient was no longer agitated or combative during the remainder of her hospitalization. She was cooperative and ambulatory and was discharged. Memantine is cleared primarily through the kidneys and should be renally dosed. Drugs that interfere with elimination-that is, other drugs utilizing the organic cation transporter-2 in the tubule, such as trimethoprim, metformin, or imipramine-may lead to drug accumulation. Our patient, who had impaired renal function, developed severe myoclonus and delirium after trimethoprim was added to therapy with memantine. As there were no reports of myoclonus and delirium with this drug combination and because of the structural, pharmacologic, and pharmacokinetic similarities between the aminoadamantanes memantine and amantadine, we researched similar dual adverse effects reported with amantadine. Amantadine has led to the same adverse effects noted in our patient, not only in patients with renal impairment, but also in one patient when trimethoprim was added to a stable dose of amantadine. This is the first reported case of a drug interaction between memantine and trimethoprim, which resulted in clinically significant myoclonus and delirium. Clinicians should be aware of this potential interaction, since there have been reports of this adverse effect with the use of amantadine. Because memantine chemically and pharmacologically resembles amantadine, it is quite possible that their toxicities are similar.

Prolonged QT Interval, Syncope, and Delirium with Galantamine

To describe a case of QT interval prolongation, syncope, and delirium associated with galantamine use and to analyze similar cases related to acetylcholinesterase inhibitors (AChIs) reported to the Australian Adverse Drug Reaction Advisory Committee (ADRAC). An 85-year-old man with dementia was treated with prolonged release galantamine 8 mg daily for 1.5 years. Three months prior to the current admission, he had a syncopal episode with low blood pressure and bradycardia. Two months later, galantamine was withdrawn, but within 2 weeks, the man developed marked cognitive, behavioral, and functional deterioration and galantamine was restarted. Three weeks later, he developed syncope, delirium, hypotension, and prolonged QT interval with serious cardiac arrhythmias, in addition to vomiting and diarrhea. A complete blood cell count and biochemistry panel performed on admission were normal. No infection was detected. Galantamine and irbesartan were ceased. The delirium fully resolved in 6 days, and the QT interval shortened from 503 to 443 msec (corrected by Bazett's formula) 4 days after discontinuation of galantamine and remained normal. In the ADRAC reports, galantamine was associated with 18 cases of delirium/confusion, 8 of syncope, 13 of bradycardia, 6 of other arrhythmias or conduction abnormalities, and 6 of hypotension. Donepezil was associated with 56, 15, 26, 15, and 5, and rivastigmine with 21, 8, 6, 2, and 2, respectively, of these reactions. Five fatal outcomes were reported in association with galantamine, 11 with donepezil, and 3 with rivastigmine, including 3, 6, and 0 sudden deaths, respectively. This case, along with previously published reports and cases identified from the ADRAC database, illustrates that AChIs may lead to delirium, syncope, hypotension, and life-threatening arrhythmias. The Naranjo probability scale indicated that galantamine was the probable cause of QT interval prolongation, syncope, and delirium in this patient. Administration of galantamine and other AChIs requires vigilance and assessment of risk factors that may precipitate QT interval prolongation, syncope, and delirium.

Spinal Subdural Hemorrhage as a Cause of Post-Traumatic Delirium

A 64-year-old man with TBI was admitted to our institute. In following days, he showed unusual behavior of agitation, restlessness, emotional instability and inattention. Post-traumatic delirium was tentatively diagnosed, and donepezil was given for his cognitive dysfunction. Although there was partial relief of agitation, he sustained back pain despite medication. Lumbar magnetic resonance image revealed SDH along the whole lumbar spine, and surgical drainage was followed. Postoperatively, his agitation disappeared and further medication was discontinued. We report a unique case of post-traumatic delirium in a patient with concomitant TBI and spinal subdural hemorrhage (SDH) that resolved with operative drainage of spinal hemorrhage.

Phenomenological Distinctions Needed in DSM-V: Delirium, Subsyndromal Delirium, and Dementias

Phenomenological Distinctions Needed in DSM-V: Delirium, Subsyndromal Delirium, and Dementias