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


==Overview==
==Overview==
==Investigations==
[[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]].
 
To identify underlying etiology following investigations are recommended:
 
* Complete blood count
 
* Serum Calcium
 
* Kidney function tests
 
* Electrolytes
 
* Liver function tests
* Blood sugar level
* Thyroid function tests
* Chest X‑ray
* ECG
* Blood cultures
 
* Urinalysis
 
 
'''If indicated:
*EEG
 
*CT head
 
*B12 and folate levels
 
*Arterial blood gases
 
*Specific cultures eg urine, sputum
 
*Lumbar puncture


==Other Diagnostic Studies==
# '''EEG'''
# '''Lumbar Puncture'''
===EEG===
===EEG===
* [[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]]:
:*[[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]]
*[[Conditions]] that can be identified on [[EEG]] include:
:*[[ metabolic encephalopathy]] or [[infectious encephalitis]]
:*Focal [[intracranial]] lesion, or it's a global abnormality.
* [[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>


EEG shows diffuse slowing.  EEG is useful to differentiate delirium from following condtions:
:*[[Periodic discharges]]
 
:* Triphasic waves
*dementia
:* lateralized [[rhythmic]] delta
 
:* Low voltage/generalized attenuation
*non‑convulsive status epilepticus and temporal lobe epilepsy
:* 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]].
*focal intracranial lesion, or it's a global abnormality.
* [[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]].
As exact EEG changes in delirium are not yet 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. 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.  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.
*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>
 
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 medicine 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.
* 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:
the relative power of the theta frequency band was most frequently studied, and, without exception, different between delirium and non-delirium subjects.A future study should determine whether the relative power of the theta frequency band is indeed the most affected EEG characteristic.  
:* 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>






mostfrequently studied variable was the relative power of thealpha frequency band (8 of 14 studies); next, the relativepower of the theta frequency band (7 of 14), the relativepower of the delta frequency band (5 of 14), and the peakfrequency (5 of 14).significantly different between delirium and nonpatients in all seven studies that investigated this variable. However, in two of these seven publications, onlythe lower part of the theta frequency band, and not thehigher part of the frequency band, was significantlyincreased in delirium.frequency band was related to delirium in 7 out of 8studies. One of these studies showed an increase in therelative power of the theta and a decrease in the relativepower of the alpha frequency band in several groups ofdelirium patients, but not in delirium/Parkinson’s disease of the theta, the alpha, and also the delta frequency band,were not only different between delirium and nondelirium patients, but also within patients before andduring an episode of delirium.
* [[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>
* The relative power of the theta frequency and alpha frequencies was consistently different between [[delirium ]] and non-[[delirium]] [[patients]].


frequently studied variable was the relative power of the alpha frequency band (8 of 14 studies); next, the relative power of the theta frequency band (7 of 14), the relative power of the delta frequency band (5 of 14), and the peak frequency (5 of 14). The relative power of the theta frequency band was significantly different between delirium and non-delirium patients in all seven studies that investigated this variable. However, in two of these seven publications, only the lower part of the theta frequency band, and not the higher part of the frequency band, was significantly increased in delirium. 22,23 The relative power of the alpha frequency band was related to delirium in 7 out of 8 studies. One of these studies showed an increase in the relative power of the theta and a decrease in the relative power of the alpha frequency band in several groups of delirium patients, but not in delirium/Parkinson’s disease patients. 21 Two studies showed that the relative power of the theta, the alpha, and also the delta frequency band, were not only different between delirium and nondelirium patients, but also within patients before and during an episode of delirium. 24,25 Other variables that often differed between delirium and non-delirium patients included the relative power of the delta frequency band (increased in delirium in 5 of 5 investigations that studied this) and the peak frequency (decreased in delirium in 4 of 5 investigations that studied this; online supplement). Two studies focused on bispectral index (BIS) EEG monitoring during delirium. In both studies, the BIS was significantly decreased in delirium patients as compared with non-delirium controls. 20,31 Unfortunately, one study did not specify the number of delirium patients included
===[[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===
* [[Meningism]]
Routine LP does not provide any benefit in management of delirium. However,it's helpful in suspected meningitis, ie delirium with
* [[Headache]] and [[fever]]
* 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>


==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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