Delirium

Abstract

Delirium (also known as toxic or metabolic encephalopathy) is a neurocognitive disorder characterized by impaired attention
and cognitive function. Symptoms develop acutely and tend to fluctuate throughout the day. Delirium can occur as a
complication of almost any medical condition. It is most often a complication of polypharmacy, especially in the elderly, and
is also commonly seen in patients admitted to the ICU. Although delirium is a reversible confusional state, it warrants urgent
medical attention because it may be the first sign of serious underlying disease. Treatment of delirium focuses on treating the
underlying illness and reducing exposure to exacerbating factors. Antipsychotic medications are used for the treatment of
agitation in delirious patients.

Etiology

 The exact mechanism by which delirium occurs is unknown.

 Nearly any disease can present with delirium.
 Recreational drugs (intoxication/withdrawal) and medications are a common cause.
 Risk factors
 Pre-existing brain disease (e.g., dementia, stroke)
 Polypharmacy, particularly with psychoactive drugs (but also drugs such as thiazide diuretics, which may
cause electrolyte abnormalities)
 Anticholinergics
 Benzodiazepines
 Antidepressants
 Advanced age
 Infection (e.g., UTI, pneumonia)
 Critical or terminal illness
 Alcohol use
 Electrolyte abnormalities

Clinical features

 The main symptom is an acute (hours to days) alteration in the level of awareness and attention. Other symptoms may
include:
 Illusions
 Hallucinations
 Deficits in memory
 Reversal in sleep-wake cycle
 Emotional lability
 The severity of symptoms fluctuates throughout the day and worsens in the evening.
 Alterations in psychomotor activity may occur.
 The duration of symptoms depends on the underlying illness (usually lasting weeks).

Diagnostics

Delirium is a clinical diagnosis. However, the underlying cause of the delirium must be identified. Diagnostic tests should be
tailored to the patient's history and physical examination.

 If the cause of delirium is not obvious based on the patient history and physical findings, diagnostics may include:
 Start with complete blood count, serum glucose, electrolytes, and urinalysis
 If medication or substance use is suspected: urine toxicology or serum drug levels
 If a metabolic etiology is suspected: serum creatinine, BUN, liver function tests, arterial blood gas
 If pneumonia is suspected: chest x-ray
 If a cardiac etiology (e.g., myocardial infarction, arrhythmia) is suspected: ECG
  If patient has focal neurological deficits or the initial workup is negative, further tests may include
 Neuroimaging (CT, MRI)
 Lumbar puncture: to rule our meningitis/encephalitis
 EEG: especially if the patient has a history of head trauma, stroke, or brain lesions
 Further diagnostics that may be considered: blood culture, thyroid function tests, vitamin
B , HIV, syphilis serology
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Treatment

 Management of delirium focuses on identifying and treating the underlying cause.

 Reduce exposure to modifiable risk factors and reorient the patient regularly.
 Minimize the use of restraints as much as possible.
 If the patient is agitated and poses a harm to himself or others, antipsychotics are indicated (most
commonly haloperidol).

Benzodiazepines are deliriogenic. Do not treat delirious patients with benzodiazepines unless the delirium is due to alcohol
or benzodiazepine withdrawal!