Delirium

Abdullah Boudaya

Definition

A transient, reversible, global dysfunction in cerebral

metabolism that has an acute onset

Epidemiology
Delirium occurs in 15%-18% of patients aged 65 years or

older on medical or surgical wards. Its prevalence is even

higher in certain populations- 30 % in post CABG surgery pts,
40% in post hip surgery pts and pts w advanced cancer and
81 % in ICU pts on mechanical ventilators.
The mortality is high associated with delirium impending
death in 25% of pts. In addition to increased risk of mortality,
pts tend to stay in the hospital longer than nondelirious pts

Risk factors

Patients who are at increased risk for delirium are: elderly pts

usually who also have dementia and medical morbidity, pts w

CNS disorders, post surgical pts, burn pts, drug-dependent pts
who are experiencing withdrawal

Diagnostic criteria: DSM V

A.

A disturbance in attention(i.e reduced ability to direct, focus, sustain, and shift attention) and
awareness(reduced orientation to the environment).
B. The disturbance develops over a short period of time(usually hours to a few days), represents a
change from baseline attention and awareness, and tends to fluctuate in severity during the course of a
day.
C. An additional disturbance in cognition (e.g memory deficit, disorientation, language, visuospatial
ability, or perception).
D. the disturbances in Criteria A and C are not better explained by another preexisting, established, or
evolving neurocognitive disorder and do not in the context of a severely reduced level of arousal such as
coma
E. There is evidence from the history, Physical examination, or laboratory findings that the disturbance is
a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e
due to drug of abuse or to a medication), or exposure to a toxin or is due to multiple etiologies.

Clinical Prodromal features

Restlessness
Anxiety
Irritability
Distractibility
Sleep disruption
Note: its very important to review the patients hospital medical
chart especially the nursing notes

Clinical Characteristics
Abrupt or acute onset
Waxing and waning
Difficulty sustaining attention ( distractible or unable to focus)
Disorganized thought patterns
Impaired short term memory usually secondary to attention deficits
Disorientation to time and place
Visuoconstructional impairment
Misperceptions usually illusions or hallucinations ( auditory or visual*)
In severe cases Speech and Language impairment.
Sleep-wake cycle disturbances with lethargy during the day and arousal at night .
Abnormal/ changes in EEG (e.g in Hepatic encephalopathy associated with severe slowing including triphasic
delta waves.

Differential Diagnoses

Emergent diagnosis
Medication associated with delirium

Emergent Diagnosis
WHHHHIMP
Wernickes encephalopathy or Withdrawal
Hypoxemia, Hypertension encephalopathy, Hypoglycemia, or

Hypoperfusion
Intracranial bleeding or Infection
Meningitis or encephalitis
Poisons or medications

Common medications associated with

Delirium
Anticholinergics
Sedative-hypnotics
Analgesics
Anticonvulsants
Antiparkinsonian drugs
Anti-inflammatories
Antineoplastic drugs
Antibiotics
Cardiac drugs
Sympathomimetics
Others such as Cimetidine, Lithium , disulfiram and ranitidine

Mnemonic:
I WATCH DEATH

Infection
Withdrawal
Acute metabolic
Trauma
CNS pathology
Hypoxia
Deficiencies in vitamins
Endocrinopathies
Acute vascular
Toxins or drugs
Heavy metals such as Lead, manganese and mercury

Making the diagnosis

The gold standard for diagnosis is a clinical evaluation in

which DSM criteria are used

The most useful diagnostic lab measure is the EEG.

Assessment of patients with Delirium

Physical exam
Mental status exam
Basic lab tests (cbc, cmp, serum drug levels, ABG, UA, urine

drug screen, EKG, and chest X-ray)

Other additional lab tests might be needed are: EEG, LP, Brain
CT or MRI

Delirium vs Dementia vs Depression

Treatment and management

Treatment and Management

2 separate and important aspects:
1- identification and reversal, when possible, of the reason(s)
for delirium
2- Reduce the psychiatric symptoms of delirium with
medications and environmental interventions regardless of
whether psychosis or agitation is present.

Management: medical care

Perform PE & neuro exam
Perform Lab evaluation
Discontinue nonessential medications
Monitor Vitals, fluid input & output and oxygenation
Avoid interruptions in sleep

Prevent &manage disruptive

&dangerous behaviors
Place pt in room near the nursing station
Consider a sitter if dangerous behavior occur
Maintain bed in low position and use side rails only if pt

insists on getting out of bed

Use restraints if needed
Avoid placement in a room with another delirious pt
Avoid a room cluttered with equipment or furniture

Facilitate reality

Encourage presence of family members

Reduce excessive environmental stimuli
Provide adequate day and night lighting
Orient pt to staff, surroundings and situations repetitively

Use medications as needed

Use haloperidol for agitation; give IV whenever possible to

avoid side effects and antagonizing the pt

Avoid use of benzodiazepines as sole agents, except in
alcohol or sedative-hypnotic withdrawal delirium
Avoid use of narcotics unless the pt has significant pain; but
dont use meperidine
Avoid anticholinergic medications; effects are additive

Guidelines for Haloperidol dosage

Mild: 0.5 - 2.0 mg

Moderate: 2.0 5.0 mg
Severe: 5.0 10.0 mg

Guidelines cont.
If Haloperidol is used IV, clear the IV line with normal saline prior to

bolus infusion. Heparin can precipitate intravenous haloperidol

For elderly pts use a starting dose of 0.5 2.0 mg
Allow 30 mins between doses; check QTc interval on EKG before
repeating dose
For continued agitation, double the previous dose
If no improvement after 3 doses, give 0.5 1.0 mg Lorazepam IV or
alternate lorazepam w haloperidol every 30 mins

Guidelines cont.
Once the pt is calm, add the total milligrams of haloperidol

required; administer the same number of milligrams over the

next 24 hrs
Assuming the pt remains calm, reduce the dose by 50% every
24 hrs
To convert IV to PO dosage, double the IV dose ( divide oral
dose into 2 or 3 doses)

Prognosis
Clinical duration of delirium ranges from less than 1 week to 2

months. The typical duration is 10-12 days.

The outcome possibilities are full recovery; progression to
stupor, coma, or death; seizures; chronic brain syndromes;
and injuries such as fracture or subdural hematomas from
falls
Most patients have full recovery, but only 4% -40% of pts
have a full recovery by the time of d/c

References
Clinical Manual of Psychosomatic Medicinne: A guide to
Consultation-Liaison Psychiatry by Michael Wise, MD and James
Rundell, MD-1st ed.
American Psychiatric Association: Practice guideline for the
treatment of patients with delirium
American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disordes, 4th edition