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Delirium by Rick Alan

Definition

Delirium is a clinical state characterized by an acute change in a person’s mental status. It usually comes on quickly, over hours or days. It is marked by extreme, fluctuating changes, including:

Changes in perception and sensation
Difficulties with ability to:
- Focus
- Sustain and shift attention
- Think and reason rationally
- Function normally
- Communicate clearly

Causes

Hundreds of underlying causes can result in delirium. Some of the most common causes include:

Serious medical condition (eg, brain tumor , cancer , kidney failure , heart attack , stroke , low or high blood sugar levels)
Serious illness (eg, meningitis )
Injury (eg, severe head injury , broken bone )
Surgery
Infection (eg, pneumonia , urinary tract infections )
Alcohol or drug abuse
Withdrawal from alcohol or drug abuse
Toxic effects of medicines
Toxins
Sleep deprivation
Severe constipation

Brain Tumor

Risk Factors

These factors increase your chance of developing delirium:

Having a terminal illness (eg, cancer), especially just prior to death
Having a serious illness (eg, AIDS , dementia )
Being of an advanced age
Being severely sleep deprived
Having a severe burn
Having central nervous system problems (eg, stroke , seizures , or tumors)
Being:
- Visually or hearing impaired
- Immobile
- Dehydrated
- Constipated
- Memory impaired
- Deficient in vitamins

Symptoms

Symptoms usually come on quickly. They can vary in severity, depending on the underlying cause. They can last for days, weeks, or longer. Symptoms are often worse at night and may include:

Inability to pay attention
Confusion
Memory problems
Language disturbances
Disorientation, especially in regard to:
- Time of day
- Where one is
- Who one is
Severe symptoms include:
- Misinterpretations—for example, thinking a doctor who is trying to help you is trying to hurt you
- Illusions—for example, thinking someone is someone else
- Hallucinations—seeing, hearing, or feeling things that are not there
- Emotional disturbances—for example, suddenly becoming very angry, fearful, or withdrawn for no apparent reason

Diagnosis

The doctor will ask about your symptoms and medical history. She will also do a physical exam. The doctor will ask specific questions about:

Present injury or illness
Use of medicines or illicit drugs
Time when mental state changed
How and how fast the mental state changed

There are many tests that may be used to help diagnose delirium. Depending on the specific case, any or all of these tests may be done, including:

Blood electrolytes—to measure levels of sodium , potassium , and calcium
Kidney and liver function tests
Blood glucose levels
Complete blood count (CBC)
Blood vitamin levels—such as vitamin B12 , folate , and thiamine
Thyroid function tests
Blood cultures—to look for signs of infection
Spinal tap —to look for signs of infection, inflammation, nervous system, injury, and/or cancer
Urine examination and culture—to look for signs of infection
Arterial blood gas—to check oxygen levels in the blood
Toxicology testing—to search for any illicit drugs in the body
Blood levels of medicines
Chest x-ray —a test that uses radiation to take a picture of structures inside the chest to look for signs of pneumonia
Electrocardiogram (ECG, EKG)—a test that records the heart's activity by measuring electrical currents through the heart muscle
CT scan —a type of x-ray that uses a computer to make pictures of structures inside the head
MRI scan —a test that uses magnetic waves to make pictures of structures inside the head
Electroencephalogram (EEG)—a test that record's the brain's activity by measuring electrical currents through the brain

Treatment

Delirium is first treated by identifying and treating the underlying cause. Then, symptoms are treated through medicine, psychological management, and environmental and supportive intervention.

Treatments may include:

Medication

Drugs used to treat symptoms of delirium include:

High potency antipsychotic medicines (eg, haloperidol [Haldol])
Benzodiazepines—used to treat delirium caused by alcohol withdrawal
Cholinergic medicines—used to treat delirium caused by anticholinergic medicines, which are used to treat stomach cramps and spasms in the intestines and bladder, among other treatments
Vitamins—given if the delirium is caused by a deficiency

If you are taking medicines that are worsening your confusion, then your doctor may stop these.

Psychological Management

This type of therapy involves helping the patient to:

Feel more safe and comfortable
Identify the cause of the delirium
Improve the ability to function
Calm down and feel less anxious

Environmental and Supportive Intervention

This type of treatment can be done by doctors, nurses, or caretakers. It is aimed at reorienting you to the surroundings and reducing anxiety. It can involve actions, such as:

Placing a clock and calendar in your room
Darkening the room at night and providing natural light during the day time hours
Maintaining a quiet, noise-free room
Reminding you often of the day and time, where you are, and why you are there
Placing familiar objects around you (eg, family photographs or objects from home)

Prevention

A number of steps have been shown to help prevent delirium in hospitalized patients at risk for delirium. These steps include:

Using memory orientation aids
Listening to relaxation tapes
Doing very light exercise (when possible and if recommended by your doctor)
Using vision and hearing aids (when necessary)
Drinking plenty of fluids (to prevent dehydration )

Delirium is difficult to prevent because it has so many causes and it can come on suddenly.

RESOURCES:

American Psychiatric Association http://www.psych.org/
National Institute of Mental Health http://www.nimh.nih.gov/

CANADIAN RESOURCES:

Canadian Psychiatric Association http://www.cpa-apc.org/
Canadian Psychological Association http://www.cpa.ca/

References:

American Psychiatric Association website. Available at: http://www.psych.org .
Berkow R. The Merck Manual of Medical Information . New York, NY: Pocket; 2000.
Delirium. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/what.php . Updated January 2010. Accessed January 21, 2010.
National Institutes of Mental Health website. Available at: http://www.nimh.nih.gov.

Last reviewed December 2011 by J. Thomas Megerian, MD, PhD, FAAP

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