Delirium management question

[jamesac1996!]

Good morning everyone. I had a couple questions regarding delirium work up and management that I was wondering if anyone could shed some light on. I understand that symptoms of delirium can resolve within hours to days but in other cases may last weeks or months. Is there anything that may indicate whether a delirium will resolve quickly or take longer? Is the duration of symptoms dependent on etiology and/or patient’s comorbitidies? And if so, is there a resource that gives rough estimates as to how long a delirium may last for a given etiology (ie. UTI vs uremic encephalopathy vs meningoencephalitis, etc.), or is it seemingly random (and yes, I am aware delirium often has multiple simultaneous contributors)? I have seen patients recover fairly quickly when their UTI is identified and treated but have had other delirious patients with several potential contributing etiologies that, after correction of said etiologies, were minimally improved weeks later.


I guess the ultimate question I’m really trying to answer with all this is: When should I continue the search for an additional uncorrected etiology for my patient’s delirium versus assuming it is just taking a while to resolve?


I will give an example of a patient I saw recently in the hospital. The patient is an older gentleman with history of unspecified dementia progressing for past couple years who presented for AMS. Without giving too much away regarding the patient’s circumstances, I will just say there is nobody to contact for collateral and very little documentation of the patient’s baseline, but seemingly he had an acute change in mental status with waxing/waning confusion and had not been eating well for several days. On admission he looked dehydrated with a prerenal AKI, had a possible LLL pneumonia which he received Abx for, and was started on IV thiamine and fluids. He was still intemittently spiking fevers so was started on empiric meningoencephalitis tx. Team was unable to get CSF after multiple LP attempts but patient no longer fevering, and AKI is resolved. It’s been a couple weeks since and the patient has shown minor improvement (again, don’t know baseline though).


So say you’ve done a basic delirium work up and a patient has a couple identifiable factors that may be contributing to their delirium. You treat them but patient is slow to improve. In the absence of other physical exam or lab findings that would prompt a specific investigation, how long would you wait before investigating for further causes versus attributing the patient’s mental status changes to what you have already identified and treated (assuming they are just taking a while to improve)?


And just to clarify for moderators, I am not looking for specific advice on the above patient I described, just providing an example for my questions.

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[thelastpsych]

Although delirium is generally considered an acute and reversible encephalopathy, more papers are coming out that demonstrate that a lot of patients never return to their baseline, or may continue to demonstrate altered mental status for weeks or even months (Source: Association of Delirium With Long-term Cognitive Decline: A Meta-analysis. JAMA Neurol. 2020).

I don't know if some delirium etiologies take longer to resolve than others, but patients with a worst baseline (dementia, limited daily functionality, multiple comorbidities) surely take more time to get better than other patients.
A few questions I would ask: Do you have an accurate baseline from family member, especially the ones who were the caretakers? Any psychiatric history? A lot of cases, if medicine is doing it's job correctly, you should wait and follow the patient - a red flag would be noy only the patient not getting better, but actively worse..

 

[comp1]

The OP has a good example. It's my opinion that, pretty uniformly, people overstate their loved one's baselines. I base this on the extensive documentation we have in charting in EMR dating back to the mid 90's for most patients. However, in this case, the OP has no baseline to speak of AND they believe the patient has dementia. There is no particular reason to think the patient will get any better. This was clearly a patient who, at baseline, could not seek help or care for themselves given the severity of their initial presentation. I definitely agree that whole concept of delirium as something "reversible" is only relevant when directly compared to dementia. It's not really, there will be residual deficits. I would argue delirium is instead sometimes "reducible" in its effect whereas dementia is not. Delirium represents a brain injury of some sort. Yes, you can reverse the cause and maybe heal a bit, but it's already done damage and that's not likely going away completely. That's not how the brain works. In terms of timelines, not going to happen, sorry. It will be entirely unique to the patient. For any patient you can only be confident in saying that there will likely still be noticeable deficits in the weeks to months timeframe, and possibly much longer. The older and sicker the patient, the longer to any sort of visible recovery, much less anything resembling resolution if that even ever happens.

 

[Stagg737]

The OP has a good example. It's my opinion that, pretty uniformly, people overstate their loved one's baselines. I base this on the extensive documentation we have in charting in EMR dating back to the mid 90's for most patients. However, in this case, the OP has no baseline to speak of AND they believe the patient has dementia. There is no particular reason to think the patient will get any better. This was clearly a patient who, at baseline, could not seek help or care for themselves given the severity of their initial presentation. I definitely agree that whole concept of delirium as something "reversible" is only relevant when directly compared to dementia. It's not really, there will be residual deficits. I would argue delirium is instead sometimes "reducible" in its effect whereas dementia is not. Delirium represents a brain injury of some sort. Yes, you can reverse the cause and maybe heal a bit, but it's already done damage and that's not likely going away completely. That's not how the brain works. In terms of timelines, not going to happen, sorry. It will be entirely unique to the patient. For any patient you can only be confident in saying that there will likely still be noticeable deficits in the weeks to months timeframe, and possibly much longer. The older and sicker the patient, the longer to any sort of visible recovery, much less anything resembling resolution if that even ever happens.

I agree with almost all of this but will push back on the bolded. I do agree that there are many patients, often the elderly who already have cognitive deficits or those who are severely ill/injured who develop delirium who will have permanent sequelae. However, I see younger people (ie <60) in the hospital who have acute delirious episodes who fully recover to baseline, frequently when the delirium is 2/2 meds the primary team is giving for pain or anxiety (you know the ones). And I'm not talking about "delirium" that's really an opioid-induced psychosis or just paradoxical disinhibition with benzos right after they get dosed, I'm talking about legit delirium.

Agree that OP's example is likely going to continue to show deficits, probably significant ones, and that delirium on dementia likely creates a new and worse cognitive baseline.

To OP, the biggest things that are going to result in worse outcomes with delirious patients are older age, presence of cognitive deficits (dementia, TBI, etc) prior to delirium, and severity of the medical illness leading to delirium. The severity of medical illness can include number of problems, length of treatment required, acuity level (ICU does worse than general or step-down units), number of meds required, intubation status, etc. Generally speaking the 60 yo with a UTI who was admitted after family noticed they were confused for a few hours and responds well to Abx in a day or two is going to do a lot better than the 80 yo with a UTI on opioids and benzos who came in after they fell and hit their head, had to be intubated in the ICU for sepsis and then developed aspiration pneumonia and is on TPN for 2 weeks.

 

[comp1]

I suppose there are delirious young people out there who exist, I just never seem to get consulted on them...

 

[Sushirolls]

We call them substance induced...

In some ways its splitting hairs when the 70yo with opioids/benzos/antihistamines etc tips over into delirium because of medications.

 

[Candidate2017]

I guess the ultimate question I’m really trying to answer with all this is: When should I continue the search for an additional uncorrected etiology for my patient’s delirium versus assuming it is just taking a while to resolve?

Are you an internist or psychiatrist? Or resident or med student?

Biological processes/diseases tend to proceed exponentially. Things creep along gradually, and then the dam breaks loose and there's no turning back (i.e., oxygen desaturation curve, organogenesis, compound interest, falling out of love/divorce). Dementia is one of these processes. Philosophically, at some point, consciousness no longer waxes and wanes. It just wanes. The end. Given this guy's presentation, he is closer to the end than the beginning.

Assuming basic medical workup has been done and medical treatment instituted, this is a social work placement issue, with a stop along the way to our cheery PM&R colleagues.

 

[sloh]

Are you an internist or psychiatrist? Or resident or med student?

Biological processes/diseases tend to proceed exponentially. Things creep along gradually, and then the dam breaks loose and there's no turning back (i.e., oxygen desaturation curve, organogenesis, compound interest, falling out of love/divorce). Dementia is one of these processes. Philosophically, at some point, consciousness no longer waxes and wanes. It just wanes. The end. Given this guy's presentation, he is closer to the end than the beginning.

Assuming basic medical workup has been done and medical treatment instituted, this is a social work placement issue, with a stop along the way to our cheery PM&R colleagues.

This thread is so timely. Just a week ago I had to notify a family member of a patient residing in a SNF who inconsistently follows 1 step commands that the patient would likely not be returning to her baseline cognition. Patient was discharged from the hospital 6 months ago. No primary cerebral insult but a host of comorbidities stacked on top of septic shock (UTI).

 

[Stagg737]

We call them substance induced...

In some ways its splitting hairs when the 70yo with opioids/benzos/antihistamines etc tips over into delirium because of medications.

I don't really consider that delirium in the younger crowd since sensorium is less likely to wax and wane and they're more likely to just be encephalopathic until whatever substance wears off, DTs being a bit of an exception.

I'm talking more of the 30-something year old gets admitted to the ICU after a car wreck or burns and after 2 weeks in the hospital starts having periods of being disoriented/hallucinating without a bunch of opiates on board. Yes, it's much less common but we see it a few times a month.

 

[clement]

Good morning everyone. I had a couple questions regarding delirium work up and management that I was wondering if anyone could shed some light on. I understand that symptoms of delirium can resolve within hours to days but in other cases may last weeks or months. Is there anything that may indicate whether a delirium will resolve quickly or take longer? Is the duration of symptoms dependent on etiology and/or patient’s comorbitidies? And if so, is there a resource that gives rough estimates as to how long a delirium may last for a given etiology (ie. UTI vs uremic encephalopathy vs meningoencephalitis, etc.), or is it seemingly random (and yes, I am aware delirium often has multiple simultaneous contributors)? I have seen patients recover fairly quickly when their UTI is identified and treated but have had other delirious patients with several potential contributing etiologies that, after correction of said etiologies, were minimally improved weeks later.


I guess the ultimate question I’m really trying to answer with all this is: When should I continue the search for an additional uncorrected etiology for my patient’s delirium versus assuming it is just taking a while to resolve?


I will give an example of a patient I saw recently in the hospital. The patient is an older gentleman with history of unspecified dementia progressing for past couple years who presented for AMS. Without giving too much away regarding the patient’s circumstances, I will just say there is nobody to contact for collateral and very little documentation of the patient’s baseline, but seemingly he had an acute change in mental status with waxing/waning confusion and had not been eating well for several days. On admission he looked dehydrated with a prerenal AKI, had a possible LLL pneumonia which he received Abx for, and was started on IV thiamine and fluids. He was still intemittently spiking fevers so was started on empiric meningoencephalitis tx. Team was unable to get CSF after multiple LP attempts but patient no longer fevering, and AKI is resolved. It’s been a couple weeks since and the patient has shown minor improvement (again, don’t know baseline though).


So say you’ve done a basic delirium work up and a patient has a couple identifiable factors that may be contributing to their delirium. You treat them but patient is slow to improve. In the absence of other physical exam or lab findings that would prompt a specific investigation, how long would you wait before investigating for further causes versus attributing the patient’s mental status changes to what you have already identified and treated (assuming they are just taking a while to improve)?


And just to clarify for moderators, I am not looking for specific advice on the above patient I described, just providing an example for my questions.

Mental status lags behind corrections as a rule.