Delirium

An acute confusional state caused by a disturbance in global cortical function. Features include disturbance of consciousness, change in cognition, fluctuations of symptoms, and evidence that the condition is secondary to an underlying medical condition. Frequently, multiple etiologies are present simultaneously. Delirium occurs in 30% of older medical patients during hospitalization. Patients with delirium experience prolonged hospitalization, functional decline, and are at high risk for institutionalization.

Differential Diagnosis

• Dementia
• Medical etiologies
  –Infections (e.g., UTI, pneumonia, encephalitis, meningitis)
  –Drug toxicity, including alcohol
  –Drug withdrawal (especially benzodiazepines)
  –Fluid, electrolyte, and metabolic disorders (e.g., hyponatremia, hypoglycemia, hypercalcemia, uremia, hypercarbia)
  –CHF
  –Hypoxia (multiple causes, including CHF)
  –Medications (e.g., antiarrhythmics, antidepressants, neuroleptics, analgesics, GI medications)
  –Stroke
  –Cerebral ischemia (multiple causes)
  –Complex partial seizure disorder is associated with an alteration of awareness
  • Psychiatric etiologies
    –Depression
    –Psychotic illness
    –“Sundowning”: Behavioral deterioration occurs during evening hours (typically occurs in demented institutionalized patients)

  Workup and Diagnosis

  • History should include evaluation of memory difficulties, disorientation, incoherent speech, and level of attention, and a discussion with patients’ family caregivers
    –Risk factors include advanced age, cognitive impairment (including dementia), psychiatric conditions, and severe chronic medical illness
    –Mini-mental status examination
  • Physical examination should include vitals, state of hydration, infectious foci, and neurologic exam, with complete investigation into possible medical etiologies
  • Initial labs may include serum electrolytes, BUN/creatinine, glucose, calcium, magnesium, CBC, and urinalysis
  • Pulse oximetry and/or arterial blood gas may be indicated to screen for hypoxia and/or hypercarbia
  • Thyroid function tests and vitamin B₁₂/folate levels
  • Imaging studies (e.g., head CT, chest X-ray), blood and urine cultures, and/or lumbar puncture may be indicated
  • EEG is indicated if suspect seizure disorder
    –Slowing of α rhythms and unusual slow-wave activity are common in delirium

  Treatment

  • Delirium is usually reversible with correction of the underlying cause
    –Discontinue possible contributing medications
    –Treat infection if present
    –Correct metabolic or electrolyte abnormalities
  • Pharmacologic therapy
    –Antipsychotics (e.g., haloperidol) for hallucinations, delusions, or illusions
    –Benzodiazepines (e.g., lorazepam) for anxiety, agitation, insomnia, or alcohol withdrawal
  • Environmental supports (e.g., calendars, direction signs) to help with orientation
  • Psychosocial support
  • Physical restraints paradoxically increase patient agitation; thus, other alternatives (e.g., safe environment, door alarms) should be used initially

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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