- Delirium is very common, and serious (↑ morbidity/mortality, costs, length of stay)
- Multifactorial syndrome:
| Predisposing factors | Precipitating factors |
| Pre-existing brain disease (esp. dementia) | Medications |
| Co-morbid diseases, medications | Surgery |
| Malignancy | Infection/medical illness |
| Chronic organ dysfunction | Organ dysfunction |
| Functional impairment | Immobilization |
| Dehydration, metabolic abnormalities | Electrolyte/metabolic imbalance |
| Alocholism, drug abuse | Alcohol/drug withdrawal/intoxication |
| Malnutrition, depression, vision/hearing impairment | Pain, environmental, stress |
Differential diagnosis
- Psych (depression, mania, psychosis)
- Psych pts can still get delirious when acutely ill
- If in doubt, assume delirium and r/o reversible causes
- Neuro
- Wernicke's encephalopathy (thiamine def) - may see nystagmus, oculomotor palsy, peripheral neuropathy, vestibular dysfunction
- Nonconvulsive status epilepticus - r/o with normal EEG
- CNS disease - stroke, brain tumor/mets, abscess, infectious encephalitis, autoimmune inflammation
History
- Baseline cognitive function
- Document with MMSE, Short Blessed, clock drawing, etc.
- Time course of mental status changes
- Potential precipitating factors (see above) - s/sx infection/medical illness, head trauma/focal neuro deficits, drugs, review all home meds
CAM (Confusion Assessment Method)
- Delirium is present if features 1 AND 2 are present plus either 3 OR 4
| 1 | Acute onset and fluctuating course | Dementia can have "sundowning", but assume delirium if new pattern |
| 2 | Inattention | |
| 3 | Disorganized thinking | |
| 4 | Altered level of consciousness | May be hyperactive (agitation) or hypoactive (lethargy) |
- Check for metabolic abnormality or infxn: CBC, CMP, UA, CXR, EKG
- If indicated: TSH, B12, drug levels/UDS
- If head trauma/focal neuro signs: head CT or MR
- If no other identifiable cause: CSF (if febrile); EEG rarely indicated (occult seizures)
Typically supportive care/treat underlying causes: DR. DRE
- Disease Remediation
- Treat underlying disease
- Nutrition, volume repletion, fluids/electrolyte balance
- Bowel/bladder function (avoid retention)
- Drug Removal
- Minimize benzos, narcotics (but have pain management)
- Minimize polypharmacy
- Environment
- Early mobilization
- Avoid restraints, lines (e.g. Foley)
- Frequent re-orientation (clock, calendar, window, family at bedside); cognitive stimulation during day
- Sleep hygiene
- Adaptive equipment (glasses, hearing aids)
Agitation requiring intervention
- Can have constant observation (e.g. family member or sitter), calming/familiar environment
- Minimize physical restraints - use sleeve to protect IV; soft mittens if necessary
- Use medications cautiously - if safety of pt or others is threatened (e.g. pulling out lines/tubes or violent)
- Psychoactive meds may worsen delirium or increase fall risk
- Typically use antipsychotics (nothing is actually indicated for treating agitation in delirium/dementia...)
- Benzos are avoided (can worsen delirium) unless indicated for -
- EtOH/benzo withdrawal
- Non-delirious anxiety
- Agitated terminal delirium
- Parkinson's (risk of EPS with Haldol); neuroleptic malignant syndrome
- If severely violent/requiring immediate sedation, can use Haldol 5/Ativan 2
- Otherwise, start low dose:
| Medication | Dose | Notes | Adverse effects |
| Haloperidol/Haldol (low-dose) | 0.5-1 mg PO or IM |
IM twice as strong as PO |
Don't use in Parkinson's (EPS) Avoid IV - causes long QT Do not use Haldol-D (depot form) |
| Risperidone/Risperdal | 0.5 mg PO BID | M-tab is orally dissolving for emergency use | Hypotension |
| Quetiapine/Seroquel | 25 mg PO BID | ||
| Olanzapine/Zyprexa | 2.5-5 PO QD | Anticholinergic + BZD activity (not in combination with parenteral benzo) | |
| Lorazepam/Ativan | 0.5-1mg PO Q4hr PRN | IV only in emergency Onset ~ 30 min |
Worsening delirium Paradoxical excitation Resp. depression, oversedation |