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Delirium, Alcohol Withdrawal and Psychiatric Disorders

Thomas Muse, MD and Rondi Gelbard, MD

Department of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA

A 77‐year‐old man with Parkinson’s disease is admitted to the hospital after a fall at home, sustaining a femur fracture and multiple rib fractures. The day after admission, he undergoes femur fixation. The patient sleeps for most of the following day and that evening he frequently attempts to get out of bed despite redirection, pulls out an IV, and becomes combative with hospital staff. The ideal treatment of this patient’s condition includes which of the following:
1. Diazepam
2. Haloperidol
3. Risperidone
4. Ziprasidone
5. Quetiapine
This patient is most likely suffering from hyperactive delirium. Of the medications listed, quetiapine has the safest side effect profile for a patient with Parkinson’s dementia and the treatment of delirium. Atypical antipsychotics are the preferred medical treatment of delirium in the elderly population, particularly those with Parkinson’s. This is due to these medications having decreased likelihood of exacerbating extrapyramidal symptoms compared to typical antipsychotics. The likelihood of developing extrapyramidal symptoms is relative to the medications’ potency for the D2 dopamine receptor. Of the atypical antipsychotics listed above (risperidone, ziprasidone, and quetiapine), the choice with the least potency for the D2 receptor is quetiapine. Benzodiazepines such as diazepam should be avoided in the elderly for treatment of delirium.

Answer: E

Devlin JW, Roberts RJ, Fong JJ, et al. Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double‐blind, placebo‐controlled pilot study. Crit. Care Med. 2010; 38(2):419–427.

Alexopoulos GS, Streim J, Carpenter D, et al. Using antipsychotic agents in older patients. J. Clin. Psych. 2004; 65(Suppl 2):5–99.

Fick DM, Agostini JV, and Inouye SK . Delirium superimposed on dementia: a systematic review. J. Am. Geriatr. Soc. 2002; 50(10):1723–1732.

Inouye SK, Westendorp RG, and Saczynski JS . Delirium in elderly people. Lancet 2014; 383(9920):911–922.

Lundstrom M, Edlund A, Bucht G, et al. Dementia after delirium in patients with femoral neck fractures. J. Am. Geriatr. Soc. 2003; 51(7):1002–1006.

A 72‐year‐old woman with no medical history presents to the emergency department as a passenger involved in a motor vehicle collision. Her injuries include five right‐sided rib fractures, a sternal fracture, and a grade 2 liver laceration. A CT scan of her head at admission showed no evidence of intracranial hemorrhage. She is admitted to the ICU for pain control and pulmonary toilet. On hospital day three, she develops intermittent periods of confusion, disorientation to place and time, and believes her bedside nurse is her daughter. Her family members state that she has never behaved in this manner previously. Her vital signs are normal including a pulse oximetry reading of 99% on room air. Routine lab work including a metabolic panel and complete blood count are normal. Abdominal exam is unremarkable. The most appropriate initial evaluation of her condition includes which of the following:

MRI brain
Blood and urine cultures
Confusion Assessment Method for the ICU (CAM‐ICU) score
Ventilation/perfusion (V/Q) lung scan
Repeat CT scan of the abdomen and pelvis with intravenous contrast

This patient has developed acute delirium as indicated by the waxing and waning nature of her symptoms. She has many risk factors including advanced age, admission to the ICU, and acute pain due to trauma. The most appropriate initial evaluation is to perform a CAM‐ICU assessment (Table 13.1). This tool has a high sensitivity and specificity for delirium and can even be used in ventilated patients. While confusion and hallucinations can be present in traumatic brain injury or degenerative brain disorders, the patient had a negative initial CT scan of the brain and no prior signs of dementia according to her family, thus a MRI of the brain is unlikely to be diagnostic. Geriatric patients may not mount a febrile response to commonly encountered infections such as urinary tract infections or pneumonia; however, this patient’s vitals and lab work are normal and therefore infection is less likely. Ventilation/perfusion lung scans are used to determine the probability of pulmonary embolism. This patient has normal vital signs including oxygen saturation and therefore this test is unlikely to be helpful in this setting. This patient has a blunt solid organ injury and is at risk for intra‐abdominal hemorrhage; however, with normal vital signs, lab work, and a benign abdominal exam, a repeat abdominal CT is unlikely to aid in diagnosis.

Table 13.1 Confusion assessment method to assess delirium (CAM).

Feature	Assessment
Acute onset and fluctuating course	Based on change from patient’s baseline. Positive response to: “Is this mental status change acute?” “Is this mental status change fluctuating during the course of the day?”
Inattention	Positive response to: “Is there difficulty focusing attention, distractibility, or difficulty keeping track of what is being said?”
Disorganized Thinking	Positive response to: “Are there rambling, irrelevant conversation, unclear, illogical thoughts, frequent and unpredictable switching from subject to subject.”
Altered level of Consciousness	Positive response if other than “alert” Normal = alert Hyper alert = vigilant Drowsy, easily aroused = lethargic Difficult to arouse = stupor Unarousable = coma
Delirium =	Features 1 AND 2 + either 3 OR 4

Answer: C

Devlin JW, Skrobik Y, Gelinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit. Care Med. 2018; 46(9):e825‐e873.

Adamis D, Rooney S, Meagher D, et al. A comparison of delirium diagnosis in elderly medical inpatients using the CAM, DRS‐R98, DSM‐IV and DSM‐5 criteria. Int. Psychogeriatr. 2015; 27(6):883–889.

A 79‐year‐old man is hospitalized for three weeks following an antrectomy and Billroth II reconstruction for gastric outlet obstruction due to peptic ulcer disease. His hospital course was complicated by delayed gastric emptying requiring prolonged nasogastric tube decompression and parenteral nutrition. The patient spent over one week of his hospitalization in the ICU primarily due to hyperactive delirium which was difficult to manage. Of the following, which is true regarding the effects of delirium in this patient population:
1. Delirium has no effect on inpatient mortality risk.
2. The duration of delirium has no long‐term effects on this patient’s risk for mortality after discharge.
3. His episodes of delirium could worsen the progression of any underlying degenerative brain disorders such as Alzheimer’s dementia.
4. Inpatient delirium episodes do not convey long‐term risk on cognitive impairment.
5. The patient is less likely to require transition to a skilled nursing facility upon discharge because of his prolonged hospital stay.
This patient’s prolonged hospital course and episodes of delirium convey a significant long‐term survival and cognitive prognosis risk. Patients who suffer from delirium during their hospitalization have double the risk of death at 1 month and 6 months after discharge. The duration of delirium also conveys added risk of mortality, as increasing days adds increasing risk of death. Additionally, delirium encountered while inpatient has been shown to increase future cognitive decline and accelerate existing cognitive decline in dementia patients. Elderly patients with extended hospitalizations are at increased risk of discharge to a skilled nursing facility.

Answer: C

Girard TD, Jackson JC, Pandharipande PP, et al. Delirium as a predictor of long‐term cognitive impairment in survivors of critical illness. Crit. Care Med. 2010; 38(7):1513–1520.

Pandharipande PP, Girard TD, Jackson JC, et al; BRAIN‐ICU Study Investigators. Long‐term cognitive impairment after critical illness. N. Engl. J. Med. 2013; 369(14):1306–1316.

Goldberg TE, Chen C, Wang Y, et al. Association of delirium with long‐term cognitive decline. A meta‐analysis. JAMA Neurology. 2020; 77:1373–1381.

Pisani MA, Kong SY, Kasl SV, et al. Days of delirium are associated with 1‐year mortality in an older intensive care unit population. Am. J. Respir. Crit. Care Med. 2009; 180(11):1092–1097.
A 52‐year‐old woman with a history of hypertension and depression is being treated for acute uncomplicated diverticulitis with ciprofloxacin and metronidazole. By hospital day two, her abdominal pain has improved and her home medications (lisinopril and sertraline) are restarted. The following day, she develops recurrent nausea which is treated with ondansetron. That evening, she becomes delirious and is given 2 mg of IV haloperidol. An hour later, her telemetry shows intermittent polymorphic ventricular tachycardia with a characteristic twisting of the QRS complex. The patient feels dizzy but is otherwise awake, alert, and hemodynamically stable. What is the appropriate next step in management?
1. Perform defibrillation.
2. Begin an IV magnesium sulfate infusion and discontinue other possible offending medications.
3. Administer a 1 liter crystalloid fluid bolus.
4. Obtain a CT scan of the abdomen and pelvis with oral and IV contrast.
5. Obtain an echocardiogram.
This patient is experiencing intermittent torsades de pointes, a form of polymorphic ventricular tachycardia where the electrocardiogram tracing will show a characteristic twisting of the QRS complex above and below the isoelectric baseline. The most likely etiology for this patient’s torsades de pointes is prolonged QT interval from administration of multiple medications which are known to cause QT prolongation. In this case, ciprofloxacin, sertraline, ondansetron, and haloperidol cause QT prolongation. Coadministration of multiple medications that prolong the QT interval increases the risk of developing QT prolongation. The correct management is to administer an IV magnesium sulfate infusion and to discontinue these medications. Defibrillation is inappropriate due to the patient being awake and hemodynamically stable. If the patient were to decline into ventricular fibrillation, then defibrillation would be appropriate. Worsening diverticulitis is unlikely to be the cause of her torsades de pointes and obtaining a CT scan would only prolong treatment. An echocardiogram would not reveal the etiology of her arrhythmia and would also prolong treatment. A fluid bolus would not be helpful in this scenario.

Answer: B

Roden DM . Predicting drug‐induced QT prolongation and torsades de pointes. J. Physiol. 2016; 594(9):2459–2468.

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