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Delirium is acute onset & fluctuating disturbance in mental state that causes patient appear confused, disoriented or with difficulty to focus and with decline in cognitive function (memory, orientation, speech), circadian disturbance and behavior of patient either agitated or sleepy,in other words sudden confusion. Delirium, also known as acute confusional state, is an organically-caused decline from a previously baseline level of mental function that develops over a short period of time (hours to days). Delirium is not a disease itself, but a syndrome encompassing disturbances in attention, consciousness, and cognition. It may also involve other neurological deficits, like psychomotor disturbances (e.g. hyperactive, hypoactive, or mixed), impaired sleep-wake cycle, emotional disturbances, and perceptual disturbances (e.g. hallucinations and delusions).
Delirium probably results from several pathophysiological mechanisms, including disturbance of action of several neurotransmitter systems within the brain, but the underlying mechanisms are not fully understood. The most widely postulated theory is that delirium is caused by cholinergic deficiency with an excess of dopamine.
Post-operative delirium has many causes as neurological diseases(as head injury, intracranial neoplasm,eplipsy),systemic illness as metabolic disease(hepatic encephalopathy,uremic hypoxia),endocrinal (hypo/hyper thyrodism ), drug induced as (antidepressant ,antibiotics ,anticonvulsants ).
The reticular formation and its connections, the main sites of arousal and attention, are involved in delirium. Dysfunction of this system may affect the perception and interpretation of environmental stimuli in delirious patients. The reduction or over activity of the environmental factors may exacerbate the symptoms of delirium, so environmental therapy and psychological support is one of the very important lines of treatment of post-operative delirium.
Many studies suggest that non-pharmacological interventions can reduce the incidence of delirium. Effective interventions, including multicomponent approach frequently focuses on predisposing factors in an individual patient. However, environmental prevention, such as re-orientation and environmental stimulation, are also effective for preventing delirium. A strong protective factor against delirium is the routinely participation in exercise. The use of multicomponent interventions by family members can also reduce the risk of delirium
Haloperidol, a typical antipsychotic, is the most frequently used and best studied antipsychotic medication for delirium due to its few anticholinergic side effects, few active metabolites, and small likelihood of causing sedation. The main mechanisms of action of haloperidol are thought to be dopamine antagonist at cortical dopamine (D2) receptors, nigro-pstriatal pathway D2 blockade, and decrease the inhibition of acetylcholine.
All patients’ conscious level was assessed blindly using ICU-CAM score to detect the incidence of delirium among the test group. Any confusion or hallucination was reported immediately (time of onset and time of offset) The Confusion Assessment Method (CAM) was originally developed in 1988-1990, to improve the identification and recognition of delirium. Since its development, the CAM has become the most widely used test for detection of delirium world-wide, because of its strong validation results as well as its ease of use. The CAM had a sensitivity of 94-100%, specificity of 90-95%.
All patients were subjected to full history taking, clinical examination, routine laboratory investigations, ESR and CRP, CBC, metabolic causes of delirium as electrolyte disturbance, hepatic or renal abnormalities, Also respiratory cause as Co2 narcosis.also any central cause as acute cerebral infarction or cerebral hemorrhage.
Several trials stated that the usage of Haloperidol pre-operative decrease the duration and the severity of Delirium rather than the incidence of delirium. In our trial we will detect the incidence of delirium with using prophylactic haloperidol in geriatric patients undergoing Hip replacement surgery.
In our study revealed that using prophylactic pre-operative haloperidol decrease the incidence of delirium among geriatric patient as well as decreasing both the duration and the severity of delirium among the study group.