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{{Delirium}}
{{Delirium}}
{{CMG}}; {{AE}} {{PB}}; [[User:Vishal Khurana|Vishal Khurana]], M.B.B.S., M.D. [mailto:vishdoc24@gmail.com]
{{CMG}}; {{AE}} {{Sara.Zand}} {{PB}}; [[User:Vishal Khurana|Vishal Khurana]], M.B.B.S., M.D. [mailto:vishdoc24@gmail.com]


==Overview==
==Overview==
[[EEG]] and [[Lumbar puncture]] can be utilized in the management of delirium, however they are not always indicated.
[[EEG]] maybe helpful for the diagnosis of [[delirium]].  [[EEG]] findings associated with [[delirium]] include [[periodic discharges]], triphasic waves ,lateralized [[rhythmic]] delta ,low voltage/generalized attenuation, theta or delta generalized slowing.The presence of either theta or delta generalized slowing correlated strongly with [[delirium]] severity regardless of [[arousal]] state (hyper- or hypoactive) and [[comorbidities]].
 
==Other Diagnostic Studies==
==Other Diagnostic Studies==
# '''EEG'''
# '''EEG'''
# '''Lumbar Puncture'''
# '''Lumbar Puncture'''
===EEG===
===EEG===
* [[EEG]] shows diffuse slowing.  
* [[EEG]] shows diffuse slowing which is an indicator of [[delirium]] severity.<ref name="KimchiNeelagiri2019">{{cite journal|last1=Kimchi|first1=Eyal Y.|last2=Neelagiri|first2=Anudeepthi|last3=Whitt|first3=Wade|last4=Sagi|first4=Avinash Rao|last5=Ryan|first5=Sophia L.|last6=Gadbois|first6=Greta|last7=Groothuysen|first7=Daniël|last8=Westover|first8=M. Brandon|title=Clinical EEG slowing correlates with delirium severity and predicts poor clinical outcomes|journal=Neurology|volume=93|issue=13|year=2019|pages=e1260–e1271|issn=0028-3878|doi=10.1212/WNL.0000000000008164}}</ref>
* [[EEG]] is useful to differentiate [[delirium]] from following [[conditions]]:
* [[EEG]] is useful to differentiate [[delirium]] from following [[conditions]]:
*[[Dementia]]
:*[[Dementia]]<ref name="ThomasHestermann2008">{{cite journal|last1=Thomas|first1=C|last2=Hestermann|first2=U|last3=Walther|first3=S|last4=Pfueller|first4=U|last5=Hack|first5=M|last6=Oster|first6=P|last7=Mundt|first7=C|last8=Weisbrod|first8=M|title=Prolonged activation EEG differentiates dementia with and without delirium in frail elderly patients|journal=Journal of Neurology, Neurosurgery & Psychiatry|volume=79|issue=2|year=2008|pages=119–125|issn=0022-3050|doi=10.1136/jnnp.2006.111732}}</ref>
*[[Non‑convulsive status epilepticus]] and [[temporal lobe]] [[epilepsy]]
:*[[Non‑convulsive status epilepticus]] and [[temporal lobe]] [[epilepsy]]
*[[Conditions]] that can be identified on [[EEG]] e.g.
*[[Conditions]] that can be identified on [[EEG]] include:
*[[ metabolic encephalopathy]] or [[infectious encephalitis]]
:*[[ metabolic encephalopathy]] or [[infectious encephalitis]]
*Focal [[intracranial]] lesion, or it's a global abnormality.
:*Focal [[intracranial]] lesion, or it's a global abnormality.
*As exact [[EEG]] changes in [[delirium]] are yet to be identified, [[EEG]] is not used to diagnose [[delirium]]. * * *Identification of the most informative electrode, and use of fewer [[electrodes]] will increase the usefulness of [[EEG]] in delirium.
* [[EEG]] findings associated with [[delirium]] include:<ref name="KimchiNeelagiri2019">{{cite journal|last1=Kimchi|first1=Eyal Y.|last2=Neelagiri|first2=Anudeepthi|last3=Whitt|first3=Wade|last4=Sagi|first4=Avinash Rao|last5=Ryan|first5=Sophia L.|last6=Gadbois|first6=Greta|last7=Groothuysen|first7=Daniël|last8=Westover|first8=M. Brandon|title=Clinical EEG slowing correlates with delirium severity and predicts poor clinical outcomes|journal=Neurology|volume=93|issue=13|year=2019|pages=e1260–e1271|issn=0028-3878|doi=10.1212/WNL.0000000000008164}}</ref>
* Continuous [[EEG]] monitoring has proven to be a feasible approach in the management of [[Epilepsy]], therefore [[EEG]] beholds a great potential to improve detection rates of [[delirium]].
 
:*[[Periodic discharges]]
:* Triphasic waves
:* lateralized [[rhythmic]] delta
:* Low voltage/generalized attenuation
:* Theta or delta generalized slowing
* The presence of either theta or delta generalized slowing correlated strongly with [[delirium]] severity regardless of [[arousal]] state (hyper- or hypoactive) and [[comorbidities]].
* [[EEG]] changes in [[delirium]] are most prominent in the posterior regions.  
* [[EEG]] changes in [[delirium]] are most prominent in the posterior regions.  
*[[Delirium]] shows slowing of background activity, however, slowing of background activity is also observed in deep sleep and dementia.  [[EEG]] recording of sleep shows K complexes and sleep-spindles whereas [[EEG]] recorded with eyes open (active [[EEG]]) in delirium have the relative power in the delta and the upper half of the alpha frequency band significantly different from dementia. These differences can be exploited to differentiate delirium from sleep and [[dementia]]. 
* [[Delirium]] shows slowing of background activity, however, slowing of background activity is also observed in deep [[sleep]] and [[dementia]].
There are many practical limitations of [[EEG]] studies in delirium. The exact effects of drugs like [[haloperidol]] on [[EEG]] are unknown, this poses a problem to study [[EEG]] characteristics of delirium, as [[haloperidol]] is the most widely used medicines in the management of delirium. Also, because of the very fluctuating nature of delirium, many studies suffer from time gap between diagnosis of delirium and [[EEG]] recordings.
*Typical and atypical [[antipsychotic]] may cause [[EEG]] abnormality.<ref name="YılmazErbaş2013">{{cite journal|last1=Yılmaz|first1=Mustafa|last2=Erbaş|first2=Oytun|title=The effects of typical and atypical antipsychotics on the electrical activity of the brain in a rat model|journal=Journal of Clinical and Experimental Investigations|volume=4|issue=3|year=2013|issn=13096621|doi=10.5799/ahinjs.01.2013.03.0284}}</ref>
Most studies have noticed difference in the relative power of the theta frequency in delirium and non-delirium patients. However, some studies have found this relative difference in theta frequency was restricted to the lower part and these studies failed to observe any difference in the higher part of the theta frequency.  One study observed an increase in the relative power of the theta and a decline in the relative power of the alpha frequency band, but this phenomenon seen to be absent when Parkinson is a co-morbid condition to delirium. More work needs to be done on the theta, alpha and delta waves as many studies have disputed given findings. Delirium can also be identified from non delirium states by the following characteristics, as delirium shows an increase in the relative power of the delta frequency band, a decreased in the peak frequency and significantly decreased bispectral index (BIS).<ref>{{Cite web  | last =  | first =  | title = What are the opportunities f... [J Neuropsychiatry Clin Neurosci. 2012] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/23224454 | publisher =  | date =  | accessdate = }}</ref>
   
* One study observed an increase in the relative power of the theta and a decline in the relative power of the alpha frequency band, but this phenomenon seen to be absent when [[Parkinson]] is a co-morbid [[condition]] to [[delirium]].<ref name="CozacGschwandtner2016">{{cite journal|last1=Cozac|first1=Vitalii V.|last2=Gschwandtner|first2=Ute|last3=Hatz|first3=Florian|last4=Hardmeier|first4=Martin|last5=Rüegg|first5=Stephan|last6=Fuhr|first6=Peter|title=Quantitative EEG and Cognitive Decline in Parkinson’s Disease|journal=Parkinson's Disease|volume=2016|year=2016|pages=1–14|issn=2090-8083|doi=10.1155/2016/9060649}}</ref>
* [[Delirium]] can also be identified from non [[delirium]] states by the following characteristics:
:* Increase in the relative power of the delta frequency band
:* Decrease in the peak frequency and significantly decreased bispectral index (BIS).<ref>{{Cite web  | last =  | first =  | title = What are the opportunities f... [J Neuropsychiatry Clin Neurosci. 2012] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/23224454 | publisher =  | date =  | accessdate = }}</ref>






====[[Neurophysiology]]====
* [[Delirium]] has been known to be associated with a generalised slowing of background activity.<ref>{{cite journal|last=Engel|first=GL|coauthors=Romano, J|title=Delirium, a syndrome of cerebral insufficiency. 1959.|journal=The Journal of neuropsychiatry and clinical neurosciences|date=2004 Fall|volume=16|issue=4|pages=526–38|pmid=15616182|doi=10.1176/appi.neuropsych.16.4.526}}</ref><ref>{{cite journal|last=van der Kooi|first=AW|coauthors=Leijten, FS; van der Wekken, RJ; Slooter, AJ|title=What are the opportunities for EEG-based monitoring of delirium in the ICU?|journal=The Journal of neuropsychiatry and clinical neurosciences|date=2012 Fall|volume=24|issue=4|pages=472–7|pmid=23224454|doi=10.1176/appi.neuropsych.11110347}}</ref>
[[Electroencephalography]] ([[EEG]]) is an attractive mode of study in delirium as it has the ability to capture measures of global brain function.  There are also opportunities to summarise temporal fluctuations as continuous recordings, compressed into power spectra (quantitative [[EEG]], qEEG).  Since the work of Engel and Romano in the 1950s, [[delirium]] has been known to be associated with a generalised slowing of background activity.<ref>{{cite journal|last=Engel|first=GL|coauthors=Romano, J|title=Delirium, a syndrome of cerebral insufficiency. 1959.|journal=The Journal of neuropsychiatry and clinical neurosciences|date=2004 Fall|volume=16|issue=4|pages=526–38|pmid=15616182|doi=10.1176/appi.neuropsych.16.4.526}}</ref>
* The relative power of the theta frequency and alpha frequencies was consistently different between [[delirium ]] and non-[[delirium]] [[patients]].


A systematic review identified 14 studies for inclusion, representing a range of different populations: 6 in older populations, 3 in ICU, sample sizes between 10 and 50).<ref>{{cite journal|last=van der Kooi|first=AW|coauthors=Leijten, FS; van der Wekken, RJ; Slooter, AJ|title=What are the opportunities for EEG-based monitoring of delirium in the ICU?|journal=The Journal of neuropsychiatry and clinical neurosciences|date=2012 Fall|volume=24|issue=4|pages=472–7|pmid=23224454|doi=10.1176/appi.neuropsych.11110347}}</ref> For most studies, the outcome of interest was the relative power measures, in order: alpha, theta, delta frequencies.  The relative power of the theta frequency was consistently different between delirium and non-delirium patients.  Similar findings were reported for alpha frequencies.  In two studies, the relative power of all these bands was different within patients before and after delirium.
===[[Lumbar puncture]]===
*Routine [[LP]] does not provide any benefit in management of [[delirium]]. However,it maybe helpful in suspected [[meningitis]] when [[confusion]] is accompanied with:<ref name="Warshaw1993">{{cite journal|last1=Warshaw|first1=G.|title=The effectiveness of lumbar puncture in the evaluation of delirium and fever in the hospitalized elderly|journal=Archives of Family Medicine|volume=2|issue=3|year=1993|pages=293–297|issn=10633987|doi=10.1001/archfami.2.3.293}}</ref>


===Lumbar puncture===
Routine LP does not provide any benefit in management of delirium. However,it's helpful in suspected meningitis, i.e. delirium with
* [[Meningism]]
* [[Meningism]]
* [[Headache]] and fever<ref>{{Cite web  | last =  | first =  | title = http://www.bgs.org.uk/Word%20Downloads/delirium.doc | url = http://www.bgs.org.uk/Word%20Downloads/delirium.doc | publisher =  | date =  | accessdate =}}</ref>
* [[Headache]] and [[fever]]


==References==
==References==

Latest revision as of 09:27, 22 April 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Pratik Bahekar, MBBS [3]; Vishal Khurana, M.B.B.S., M.D. [4]

Overview

EEG maybe helpful for the diagnosis of delirium. EEG findings associated with delirium include periodic discharges, triphasic waves ,lateralized rhythmic delta ,low voltage/generalized attenuation, theta or delta generalized slowing.The presence of either theta or delta generalized slowing correlated strongly with delirium severity regardless of arousal state (hyper- or hypoactive) and comorbidities.

Other Diagnostic Studies

  1. EEG
  2. Lumbar Puncture

EEG

  • The presence of either theta or delta generalized slowing correlated strongly with delirium severity regardless of arousal state (hyper- or hypoactive) and comorbidities.
  • EEG changes in delirium are most prominent in the posterior regions.
  • Delirium shows slowing of background activity, however, slowing of background activity is also observed in deep sleep and dementia.
  • Typical and atypical antipsychotic may cause EEG abnormality.[3]
  • One study observed an increase in the relative power of the theta and a decline in the relative power of the alpha frequency band, but this phenomenon seen to be absent when Parkinson is a co-morbid condition to delirium.[4]
  • Delirium can also be identified from non delirium states by the following characteristics:
  • Increase in the relative power of the delta frequency band
  • Decrease in the peak frequency and significantly decreased bispectral index (BIS).[5]


  • Delirium has been known to be associated with a generalised slowing of background activity.[6][7]
  • The relative power of the theta frequency and alpha frequencies was consistently different between delirium and non-delirium patients.

Lumbar puncture

References

  1. ↑ 1.0 1.1 Kimchi, Eyal Y.; Neelagiri, Anudeepthi; Whitt, Wade; Sagi, Avinash Rao; Ryan, Sophia L.; Gadbois, Greta; Groothuysen, Daniël; Westover, M. Brandon (2019). "Clinical EEG slowing correlates with delirium severity and predicts poor clinical outcomes". Neurology. 93 (13): e1260–e1271. doi:10.1212/WNL.0000000000008164. ISSN 0028-3878.
  2. ↑ Thomas, C; Hestermann, U; Walther, S; Pfueller, U; Hack, M; Oster, P; Mundt, C; Weisbrod, M (2008). "Prolonged activation EEG differentiates dementia with and without delirium in frail elderly patients". Journal of Neurology, Neurosurgery & Psychiatry. 79 (2): 119–125. doi:10.1136/jnnp.2006.111732. ISSN 0022-3050.
  3. ↑ Yılmaz, Mustafa; Erbaş, Oytun (2013). "The effects of typical and atypical antipsychotics on the electrical activity of the brain in a rat model". Journal of Clinical and Experimental Investigations. 4 (3). doi:10.5799/ahinjs.01.2013.03.0284. ISSN 1309-6621.
  4. ↑ Cozac, Vitalii V.; Gschwandtner, Ute; Hatz, Florian; Hardmeier, Martin; Rüegg, Stephan; Fuhr, Peter (2016). "Quantitative EEG and Cognitive Decline in Parkinson's Disease". Parkinson's Disease. 2016: 1–14. doi:10.1155/2016/9060649. ISSN 2090-8083.
  5. ↑ "What are the opportunities f... [J Neuropsychiatry Clin Neurosci. 2012] - PubMed - NCBI".
  6. ↑ Engel, GL (2004 Fall). "Delirium, a syndrome of cerebral insufficiency. 1959". The Journal of neuropsychiatry and clinical neurosciences. 16 (4): 526–38. doi:10.1176/appi.neuropsych.16.4.526. PMID 15616182. Unknown parameter |coauthors= ignored (help); Check date values in: |date= (help)
  7. ↑ van der Kooi, AW (2012 Fall). "What are the opportunities for EEG-based monitoring of delirium in the ICU?". The Journal of neuropsychiatry and clinical neurosciences. 24 (4): 472–7. doi:10.1176/appi.neuropsych.11110347. PMID 23224454. Unknown parameter |coauthors= ignored (help); Check date values in: |date= (help)
  8. ↑ Warshaw, G. (1993). "The effectiveness of lumbar puncture in the evaluation of delirium and fever in the hospitalized elderly". Archives of Family Medicine. 2 (3): 293–297. doi:10.1001/archfami.2.3.293. ISSN 1063-3987.

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