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DELIRIUM

LEARNING OBJECTIVES:
At the end of this tutorial, you should be able to:
1. Define and classify delirium.
2. Form a differential diagnosis for the aetiology of delirium.
3. Outline the causes of deliriume
4. Take a history from patients with delirium, and take a collateral history,
looking for features which may assist in narrowing the differential.
5. Examine patients with deliriumto elicit features suggestive of underlying
aetiology.
6. Choosing and justifying appropriate investigations of the patient with
delirium.

DEFINITION: Delirium or acute confusional state is a transient global disorder

of cognition

PATHOPHYSIOLOGY: The mechanism of delirium still is not fully understood.

Delirium results from a wide variety of structural or physiological insults. In
delirium, an excess of dopaminergic activity occurs

There are two types of delirium described:

1. Hyperactive Delirium: Hyperactive delirium is observed in patients in a

state of alcohol withdrawal or intoxication certain illicit drugs.

2. Hypoactive Delirium: Hypoactive delirium is observed in patients in

states of hepatic encephalopathy and hypercapnia.

Almost any medical illness, intoxication, or medication can cause delirium.

Often, delirium is multifactorial in aetiology, and the physician treating the
delirium should investigate each cause contributing to it. Medications are the
most common reversible cause of delirium.

DIFFERENTIAL DIAGNOSIS:

Infectious 1. CNS infections such as meningitis

2. Encephalitis
3. HIV-related brain infections
4. Septicemia
5. Pneumonia
6. Urinary tract infections

Metabolic 1. Fluid and electrolyte abnormalities, acid-

base disturbances, and hypoxia
2. Hypoglycaemia
3. Hepatic or renal failure
4. Vitamin deficiency states (especially
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thiamine and cyanocobalamin)

5. Endocrinopathies associated with the thyroid
and parathyroid

Structural Lesions of 1. Closed head injury or cerebral haemorrhage

the Brain 2. Cerebrovascular accidents, such as cerebral
infarction, subarachnoid haemorrhage, and
hypertensive encephalopathy
3. Primary or metastatic brain tumours

Post-operative Delirium
4. Brain abscess
1. Preoperative (dementia, polypharmacy, fluid
and electrolyte imbalance)
2. Intraoperative (meperidine, long-acting
benzodiazepines, anticholinergics such as
atropine.

5. Mild cognitive impairment and vascular risk

factors can be independent risk factors for
postoperative delirium.
Medications Drugs are a common risk factor for delirium, and
drug-induced delirium is commonly seen in medical
practice, especially in hospital settings. The risk of
anticholinergic toxicity is greater in elderly
persons, and the risk of inducing delirium by
medications is high in frail, elderly persons and in
those with dementia.

1. Substance intoxication - Alcohol, heroin,

cannabis, PCP, and LSD
2. Medication-induced delirium

a) Anticholinergics (Benadryl, tricyclic

antidepressants)
b) Narcotics (meperidine)
c) Sedative hypnotics (benzodiazepines)
d) Histamine-2 (H2) blockers (cimetidine)
e) Corticosteroids
f) Centrally acting antihypertensives
(methyldopa, reserpine)
g) Anti-Parkinson drugs (levodopa)

Substance withdrawal from alcohol, opioids, and

benzodiazepines
Hypoperfusion States 1. Shock
2. Congestive heart failure
3. Cardiac arrhythmias
4. Anaemias
Other 1. Depression
2. Dementia(but both can occur together)
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Psychosis (usually associated with a previous

history of psychiatric illness)
Delirium in the Elderly

All of the above conditions apply along with:

1. Dementia is one of the strongest most consistent risk factors. Underlying

dementia is observed in 25-50% of patients. The presence of dementia
increases the risk of delirium 2-3 times.
2. In persons who are elderly, medications at therapeutic doses and levels
can cause delirium. Although numerous risk factors have been described,
a recent study identified 5 important independent risk factors:
a) Use of physical restraints
b) Malnutrition
c) Use of a bladder catheter
d) Any iatrogenic event
e) Use of 3 or more medications
The causes of delirium can be remembered with the following mnemonic:

D Drugs
E Emotional
L Low PO2 States

1. MI
2. PE
3. Anemia
4. CVA

I Infection
R Retention of urine or feces
I Ictal states
U Undernutrition/underhydration
M Metabolic

1. Electrolytes: Sodium, calcium

2. Glucose:
Hyperglycemia/Hypoglycemia
3. Thyroid
4. Thiamine or vitamin B12
deficiency

S Subdural

Acute CNS processes:

1. Epilepsy
2. Head injury
3. Space occupying
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lesion
4. Encephalitis
5. Cerebral hemorrhage

Always add
PAIN

Drugs Causing Delirium

Mnemonic = ACUTE CHANGE IN MS

A Antiparkinsonian drugs
C Corticosteroids
U Urinary incontinence (anti-
cholinesterase)
T Theophylline
E Emptying drugs (metoclopromide)

C Cardiovascular drugs (digoxin)

H H2 blockers
A Antimicrobials (Alcohol)
N NSAIDS
G Geropyschiatric drugs
E ENT drugs (decongestants, anti-
histamines)

I Insomnia drugs
N Narcotics

M Muscle relaxants
S Seizure drugs

HISTORY

Delirium can occur at any age, but it occurs more commonly in patients who are
elderly and have compromised mental status. Delirium can occur in patients
with an underlying dementia. This diagnosis here requires not only a careful
mental status but also a thorough history from the patient's family and the staff
as well as a comprehensive chart review.

The diagnosis of delirium is clinical. No laboratory test can diagnose delirium.

Obtaining a thorough history is essential.
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Because delirious patients often are confused and unable to provide

accurate information, getting a detailed history from family, caregivers,
and nursing staff is particularly important. Nursing notes can be very
helpful for documentation of episodes of disorientation, abnormal
behaviour, and hallucinations.
Delirium always should be suspected when there is an acute or subacute
deterioration in behaviour, cognition, or function occurs, especially in
patients who are elderly, demented, or depressed.
Patients may have visual hallucinations or persecutory delusions as well
as grandiose delusions.
Depression symptoms are commonly seen with delirium. Delirium is a
common cause for psychotic symptoms, bizarre delusions, abnormal
behaviour, and thought disorders. Agitated patients are at risk for violent
and abnormal behaviour .
Delirium develops in a short period of time (within hours), and an acute
change in consciousness or difficulty focusing on what was being said
could occur during the interview. Disturbance of the sleep-wake cycle
with insomnia, daytime drowsiness, or disturbing dreams or nightmares
can also occur.
Patients may have false beliefs or thinking (misinterpreting intravenous
lines as ropes or snakes) or see or hear things that are not present
(picking up things in the air or seeing bugs in the bedclothes). Delirium
in elderly patients may result in the self-removal of catheters or
intravenous tubing or attempts to get out of bed, resulting in a fall or
injury.
Main symptoms

1. Clouding of consciousness
2. Difficulty maintaining or shifting attention
3. Disorientation
4. Illusions
5. Hallucinations
6. Fluctuating levels of consciousness

Symptoms tend to fluctuate over the course of the day, with some
improvement in the daytime and maximum disturbance at night. Reversal
of the sleep-wake cycle is common.
Patients with delirium who are hyperactive have an increased state of
arousal, psychomotor abnormalities, and hypervigilance. In contrast,
patients with delirium who are hypoactive are withdrawn, less active, and
sleepy.
Hypoactive delirium sometimes is misdiagnosed as dementia or
depression.
In patients who are elderly, delirium often is the presenting symptom of
an underlying illness.

Differentiating features between delirium and dementia

Features Delirium Dementia
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Onset Acute Insidious

Course Fluctuating Progressive
Duration Days to weeks Months to years
Consciousness Altered Clear
Attention Impaired Normal, except in severe
dementia
Psychomotor Increased or Often normal
changes decreased
Reversibility Usually Rarely

EXAMINATION
A careful and complete physical examination including a mental status
examination is necessary. Testing vital signs such as temperature, pulse,
blood pressure, and respiration is mandatory. In older patients,
examination for possible lower respiratory tract infection or urinary
infection is essential.
o Patients have difficulty sustaining attention, problems in
orientation and short-term memory, poor insight, and impaired
judgment. Key elements here are fluctuating levels of
consciousness.
o Impaired attention can be assessed with bedside tests that require sustained attention to a task
that has not been memorized, such as reciting the days of the week or months of the year
backwards, counting backwards from 20, or doing serial subtraction.

DSM-IV Criteria for Delirium

1. Disturbance of consciousness (ie, reduced clarity of awareness of
the environment) occurs, with reduced ability to focus, sustain, or
shift attention.
2. Change in cognition (eg, memory deficit, disorientation, language
disturbance, perceptual disturbance) occurs that is not better
accounted for by a pre-existing, established, or evolving dementia.

3. The disturbance develops over a short period (usually hours to

days) and tends to fluctuate during the course of the day.

The mental status is a bedside or interview assessment that dramatically

fluctuates. It includes the patient's appearance, affect (mood), thoughts
(especially the presence of hallucinations and delusions), orientation,
immediate, recent, and long-term memory which can be assessed with an
MMSE examination. The Mini-Mental Status Examination (MMSE) is a
formalized way of documenting the severity and nature of mental status
changes.The maximum score is thirty and the test includes sections on
orientation, registration, attention and calculation, recall , language,
repetition and complex commands.

Daily MMSE examinations or the shorter MTS exam ( the 1 st 10 questions on

the MMSE exam) should be carried out to assess changes in the patients
mental status.
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INVESTIGATIONS:

Laboratory Studies

1. Complete blood cell count with differential - to diagnose infection and

anaemia
2. Electrolytes - To diagnose low or high levels
3. Glucose - To diagnose hypoglycemia, diabetic ketoacidosis, and
hyperosmolar nonketotic states
4. Renal and liver function tests - To diagnose liver and renal failure
5. Thyroid function studies - To diagnose hypothyroidism
6. Urine analysis - Used to diagnose urinary tract infection
7. Urine and blood drug screen - Used to diagnose toxicological causes
8. Thiamine and vitamin B-12 levels - Used to detect deficiency states of
these vitamins
9. Tests for bacteriological and viral aetiologies - To diagnose infection
10. Sedimentation rate
11. Drug screen including alcohol level
12. HIV tests

Imaging Studies
Neuroimaging
o CT brain.
o Magnetic resonance imaging (MRI) of the head may be helpful in
the diagnosis of stroke, hemorrhage, and structural lesions.
Electroencephalogram
o In delirium, generally, slowing of the posterior dominant rhythm
o In delirium resulting from alcohol/sedative withdrawal, increased
EEG fast-wave activity occurs.
o In patients with hepatic encephalopathy, diffuse EEG slowing
occurs.
Chest radiograph is used to diagnose pneumonia or congestive heart
failure.

Other Tests
Lumbar puncture is indicated when CNS infection is suspected as a cause
of delirium or when the source for the systemic infection cannot be
determined.
Electrocardiogram is used to diagnose ischemic and arrhythmic causes.