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Delirium: [Print] - eMedicine Psychiatry http://emedicine.medscape.

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eMedicine Specialties > Psychiatry > Emergency

Kannayiram Alagiakrishnan, MD, MBBS, Associate Professor, Department of Medicine, Division of Geriatric Medicine, University of Alberta
Patricia Blanchette, MD, Department Chair and Director, Geriatric Medicine Fellowship Program, Professor of Geriatric Medicine, Geriatric
Medicine, John A Burns School of Medicine, University of Hawaii
Updated: Apr 2, 2010

Introduction

Background
Delirium or acute confusional state is a transient global disorder of cognition. The condition is a medical emergency
associated with increased morbidity and mortality rates. Early diagnosis and resolution of symptoms are correlated with the
most favorable outcomes. Therefore, it must be treated as a medical emergency.

Delirium is not a disease but a syndrome with multiple causes that result in a similar constellation of symptoms. Delirium is
defined as a transient, usually reversible, cause of cerebral dysfunction and manifests clinically with a wide range of
neuropsychiatric abnormalities. The clinical hallmarks are decreased attention span and a waxing and waning type of
confusion.

Delirium often is unrecognized or misdiagnosed and commonly is mistaken for dementia, depression, mania, an acute
schizophrenic reaction, or part of old age (patients who are elderly are expected to become confused in the hospital).

The word delirium is derived from the Latin term meaning "off the track." This syndrome was reported during Hippocrates'
time, and, in 1813, Sutton described delirium tremens. Later, Wernicke described the encephalopathy that bears his name.

Case study

A 78-year-old female was brought to the Emergency Department by her daughter for vomiting, new onset urinary incontinence,
confusion, and incoherent speech for the past 2 days. The patient was disoriented and could see people climbing trees
outside the window. She had difficulty sustaining attention, and her level of consciousness waxed and waned. She had been
talking about her deceased husband. Patient was also trying to pull out her intravenous access line. Past history included
diabetes mellitus, hyperlipidemia, osteoarthritis, and stroke.

The patient's family physician had recently prescribed Tylenol with codeine for the patient's severe knee pain 5 days earlier.
On examination, the patient was drowsy and falling asleep while practitioners were talking to her. Patient was not cooperative
with the physical examination and with a formal mental status examination. Limited examination of the abdomen indicated that it
was flat and soft with normal bowel sounds. The patient moves all 4 limbs and plantar is bilateral flexor. Laboratory test results
revealed elevated BUN and creatinine levels, and the urine analysis was positive for urinary tract infection. CT scan of the head
showed cortical atrophy.
Pathophysiology
Based on the state of arousal, 3 types of delirium are described. Hyperactive delirium is observed in patients in a state of
alcohol withdrawal or intoxication with phencyclidine (PCP), amphetamine, and lysergic acid diethylamide (LSD). Hypoactive
delirium is observed in patients in states of hepatic encephalopathy and hypercapnia. In mixed delirium, individuals display
daytime sedation with nocturnal agitation and behavioral problems.

The mechanism of delirium still is not fully understood. Delirium results from a wide variety of structural or physiological insults.
The neuropathogenesis of delirium has been studied in patients with hepatic encephalopathy and alcohol withdrawal.
Research in these areas still is limited. The main hypothesis is reversible impairment of cerebral oxidative metabolism and
multiple neurotransmitter abnormalities. The following observations support the hypothesis of multiple neurotransmitter
abnormalities.

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Delirium: [Print] - eMedicine Psychiatry http://emedicine.medscape.com/article/288890-print

Acetylcholine

Data from animal and clinical studies support the hypothesis that acetylcholine is one of the critical neurotransmitters in the
pathogenesis of delirium.[1 ]Clinically, good reasons support this hypothesis. Anticholinergic medications are a well-known
cause of acute confusional states, and patients with impaired cholinergic transmission, such those with Alzheimer disease, are
particularly susceptible. In patients with postoperative delirium, serum anticholinergic activity is increased.

Dopamine

In the brain, a reciprocal relationship exists between cholinergic and dopaminergic activities. In delirium, an excess of
dopaminergic activity occurs. Symptomatic relief occurs with antipsychotic medications such as haloperidol and other
neuroleptic dopamine blockers.

Other neurotransmitters

Serotonin: Human and animal studies have found that serotonin is increased in patients with hepatic encephalopathy and
septic delirium. Hallucinogens such as LSD act as agonists at the site of serotonin receptors. Serotoninergic agents also can
cause delirium.

Gamma-aminobutyric acid (GABA): In patients with hepatic encephalopathy, increased inhibitory GABA levels also are
observed. An increase in ammonia levels occurs in patients with hepatic encephalopathy, which causes an increase in the
amino acids glutamate and glutamine, which are precursors to GABA. Decreases in CNS GABA levels are observed in
patients with delirium resulting from benzodiazepine and alcohol withdrawal.

Cortisol and beta-endorphins: Delirium has been associated with the disruption of cortisol and beta-endorphin circadian
rhythms. This mechanism has been suggested as a possible explanation for delirium caused by exogenous glucocorticoids.

Disturbed melatonin disturbance has been associated with sleep disturbances in delirium.[2 ]

Inflammatory mechanism

Recent studies have suggested a role for cytokines, such as interleukin-1 and interleukin-6, in the pathogenesis of delirium.
Following a wide range of infectious, inflammatory, and toxic insults, endogenous pyrogen, such as interleukin-1, is released
from the cells. Head trauma and ischemia, which frequently are associated with delirium, are characterized by brain responses
that are mediated by interleukin-1 and interleukin-6.[3,4 ]

Stress reaction mechanism

Studies indicate psychosocial stress and sleep deprivation facilitate the onset of delirium.

Structural mechanism

The specific neuronal pathways that cause delirium are unknown. Imaging studies of metabolic (eg, hepatic encephalopathy)
and structural (eg, traumatic brain injury, stroke) factors support the hypothesis that certain anatomical pathways may play a
more important role than others. The reticular formation and its connections are the main sites of arousal and attention. The
dorsal tegmental pathway projecting from the mesencephalic reticular formation to the tectum and the thalamus is involved in
delirium.

Disrupted blood-brain barrier can allow neurotoxic agents and inflammatory cytokines to enter the brain and may cause
delirium. Contrast-enhanced MRI can be used to assess the blood-brain barrier.[5,6 ]

Visuoperceptual deficits in delirium such as hallucinations and delusions are not due to the underlying cognitive impairment.[7
]
Visual hallucinations during alcohol-withdrawal delirium are seen in subjects with polymorphisms of genes coding for
dopamine transporter and catechol-O-methyltransferase (COMT).[8 ]

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Delirium can occur on top of an underlying dementia. No laboratory test can diagnose delirium. Therefore. especially when patients are quiet or withdrawn. and long-term disability. and hallucinations. they should not be left unattended or alone. but it occurs more commonly in patients who are elderly and have compromised mental status. Fourth Edition. or function occurs. Learning to record accurate and specific findings in mental status as well as the particular time the finding was observed is imperative for the staff. especially in patients who are elderly.[13 ]or the Geriatric Depression Scale (GDS). Delirium is present in 10-22% of elderly patients at the time of admission.[15 ]On the other hand. increased cost. In a recent study. caregivers. Prevalence of postoperative delirium following general surgery is 5-10% and as high as 42% following orthopedic surgery. Depression symptoms are commonly seen with delirium." Delirium always should be suspected when (a new onset) or an acute or subacute deterioration in behavior. and plan. Text Revision (DSM-IV-TR) criteria. 3 of 20 9/6/2010 8:43 PM . Because delirious patients often are confused and unable to provide accurate information. However. Obtaining a thorough history is essential.[9 ] Patients who develop delirium during hospitalization have a mortality rate of 22-76% and a high rate of death during the months following discharge.eMedicine Psychiatry http://emedicine. As many as 80% of patients develop delirium near death. Mortality/Morbidity In patients who are admitted with delirium. Nursing notes can be very helpful for documentation of episodes of disorientation.[14 ]They can also assess for suicidal and homicidal risk if necessary. Health professionals can directly ask patients about suicidal or homicidal ideation (thoughts). Clinical History The diagnosis of delirium is clinical. cognition. by Diagnostic and Statistical Manual of Mental Disorders. dementia cannot be diagnosed with certainty when delirium is present.[16 ]Screening for depression in the presence of delirium is quite challenging.[10 ] In patients who are elderly and patients in the postoperative period. delirium may result in a prolonged hospital stay. Delirium is mistaken for dementia or depression. patients having symptoms of dysphoric mood and hopelessness are at risk for incident delirium while in the hospital. 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. Delirium has been found in 40% of patients admitted to intensive care units. and nursing staff is particularly important. Some patients with delirium also may become suicidal or homicidal.medscape.Delirium: [Print] . demented.com/article/288890-print Frequency United States Delirium is common in the United States. Health professionals can do Mini-Mental Status Exam (MMSE). increased complications. It has been found in 14-56% of elderly patients who are hospitalized. with an additional 10-30% of cases developing after admission. Delirium is extremely common among nursing home residents. or depressed. Up to 42% of patients referred to psychiatry services for suspected depressive illness in the hospital may have delirium. Patients may have visual hallucinations or persecutory delusions as well as grandiose delusions.[12 ]depression assessment screening using DSM-IV-TR criteria. Staff should not just report "he was confused.[11 ] Age Delirium can occur at any age. getting a detailed history from family. intent. hypoactive delirium may be mistaken for depression. abnormal behavior. mortality rates are 10-26%.

or disturbing dreams or nightmares can also occur. fear. Patients may also misjudge their level of wellness and try to elope from the hospital. homicidal behavior. bizarre delusions. and anxiety. Main symptoms Clouding of consciousness Difficulty maintaining or shifting attention Disorientation Illusions Hallucinations Fluctuating levels of consciousness Symptoms tend to fluctuate over the course of the day. inquiry into self-destructive behavior. affect (mood). Prevalence rates of 30-50% have been reported in intensive care units. in this diagnosis. Patients are often unable to remember why they are in the hospital or the events that occurred during the delirious period (for most patients. Delirium in hospitalized seniors may result in the self-removal of catheters or intravenous tubing or attempts to get out of bed. judgment and. Agitated patients are at risk for violent and abnormal behavior and in rare circumstances. and long-term memory. The mental status is a bedside or interview assessment that dramatically fluctuates. daytime drowsiness. anxiety. thoughts (especially the presence of hallucinations and delusions).[17. less active. frequent calls for assistance. recent. with some improvement in the daytime and maximum disturbance at night. and hypervigilance.eMedicine Psychiatry http://emedicine. Delirium develops in a short period of time (within hours). psychomotor abnormalities.com/article/288890-print Delirium is a common cause for psychotic symptoms. Reversal of the sleep-wake cycle is common. agitation can lead to attempts of homicide. This includes sleep disturbances.Delirium: [Print] . immediate. In patients who are elderly. It includes the patient's appearance. Hypoactive delirium sometimes is misdiagnosed as dementia or depression. and thought disorders.18 ] A prodromal phase lasting for hours to days can occur before full syndromal delirium becomes evident. orientation. Subsyndromal delirium has been defined as the presence of some core diagnostic symptoms that do not meet the criteria for diagnostic threshold. vivid dreams. resulting in a fall or injury. patients with delirium who are hypoactive are withdrawn. and irritability may be seen in some patients. Neurological symptoms Dysphasia Dysarthria Tremor Asterixis in hepatic encephalopathy and uremia Motor abnormalities Patients with delirium who are hyperactive have an increased state of arousal. and sleepy. and an acute change in consciousness or difficulty focusing on what was being said could occur during the interview.[17.18 ] Physical 4 of 20 9/6/2010 8:43 PM . Emotional disturbances leading to depression. it is like a blackout period). In contrast. Disturbance of the sleep-wake cycle with insomnia. abnormal behavior. 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 often is the presenting symptom of an underlying illness.medscape.

Gaps can be noted in the measures to identify delirium.[19 ] Delirium symptom severity can be assessed by the Delirium Rating Scale (DRS) and the Memorial Delirium Assessment Scale (MDAS). pulse. language disturbance. the Mini-Cog can be used to identify patients at high risk for inhospital delirium. sustain. problems in orientation and short-term memory. such as once daily cognitive assessment and no formal assessments on the hallmarks of delirium (attention span and fluctuation). Evidence from the history. if the elderly patient does not have a history of dementia or cognitive impairment. with reduced ability to focus. established. poor insight. Testing vital signs such as temperature. 5 of 20 9/6/2010 8:43 PM . Table 1. Key elements here are fluctuating levels of consciousness. Patients have difficulty sustaining attention. Impaired attention can be assessed with bedside tests that require sustained attention to a task that has not been memorized. The physicians depend on health records (nursing notes) to identify a fluctuating course. blood pressure. disorientation. and impaired judgment.[20 ] A simple cognitive test like the Mini-Cog can be a predictor of inhospital delirium. The type of information might also be less than adequate for developing a timely diagnosis. or evolving dementia. The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day. medication use.com/article/288890-print A careful and complete physical examination including a mental status examination is necessary. except in severe dementia Psychomotor changes Increased or Often normal decreased Reversibility Usually Rarely To make an accurate diagnosis. reduced clarity of awareness of the environment) occurs. counting backwards from 20. or doing serial subtraction.eMedicine Psychiatry http://emedicine. and respiration is mandatory. Change in cognition (eg. perceptual disturbance) occurs that is not better accounted for by a preexisting. or laboratory findings is present that indicates the disturbance is caused by a direct physiologic consequence of a general medical condition. or shift attention. So the recognition of delirium can be delayed by infrequent observation or documentation.medscape. an intoxicating substance. or more than one cause. At the time of admission to the hospital. such as reciting the days of the week or months of the year backwards.Delirium: [Print] . DSM-IV-TR diagnostic criteria for delirium[13 ] Disturbance of consciousness (ie. Other diagnostic instruments are the Delirium Symptom Interview (DSI) and the Confusion Assessment Method (CAM). Differentiating Features of Delirium and Dementia Features Delirium Dementia Onset Acute Insidious Course Fluctuating Progressive Duration Days to weeks Months to years Consciousness Altered Clear Attention Impaired Normal. memory deficit. physical examination. periodic application of diagnostic criteria such as CAM or DSM-IV criteria and knowledge of the patient's baseline mental status is imperative.

and the physician treating the delirium should investigate each cause contributing to it. a recent study identified 5 important independent risk factors. Use of physical restraints Malnutrition Use of a bladder catheter Any iatrogenic event Use of 3 or more medications Dementia is one of the strongest most consistent risk factors.com/article/288890-print The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) offers the clinician the opportunity to identify delirium in critical care patients. Low educational level. Although numerous risk factors have been described. intoxication.eMedicine Psychiatry http://emedicine. The CAM-ICU makes use of nonverbal assessments to evaluate the important features of delirium. is associated with increased vulnerability to delirium. fecal impaction. and change of environment In persons who are elderly. delirium is multifactorial in etiology. The presence of dementia increases the risk of delirium 2-3 times. sleep deprivation. especially patients on mechanical ventilation. Causes Almost any medical illness. Another instrument that can be used in ICU settings is the Intensive Care Delirium Screening Checklist (ICDSC). urinary retention. which may be an indicator of low cognitive reserve. or medication can cause delirium.Delirium: [Print] . Underlying dementia is observed in 25-50% of patients.medscape. 6 of 20 9/6/2010 8:43 PM . DSM-IV-TR classification of delirium Delirium due to general medical condition Substance intoxication delirium Substance withdrawal delirium Delirium due to multiple etiologies Delirium not otherwise specified Some of the other common reversible causes include the following: Hypoxia Hypoglycemia Hyperthermia Anticholinergic delirium Alcohol or sedative withdrawal Other causes of delirium include the following: Infections Metabolic abnormalities Structural lesions of the brain Postoperative states Miscellaneous causes. medications at therapeutic doses and levels can cause delirium. such as sensory deprivation. Medications are the most common reversible cause of delirium. Often. The severity of delirium in the ICU can be estimated by the Delirium Detection Scale (DDS).

medscape. opioids. such as cerebral infarction. Structural changes Closed head injury or cerebral hemorrhage Cerebrovascular accidents. subarachnoid hemorrhage. heroin. reserpine) Anti-Parkinson drugs (levodopa) Substance withdrawal from alcohol.Alcohol. cannabis. and hypertensive encephalopathy Primary or metastatic brain tumors Brain abscess Metabolic causes Fluid and electrolyte abnormalities.eMedicine Psychiatry http://emedicine. acid-base disturbances. and hypoxia Hypoglycemia Hepatic or renal failure Vitamin deficiency states (especially thiamine and cyanocobalamin) Endocrinopathies associated with the thyroid and parathyroid Hypoperfusion states Shock Congestive heart failure Cardiac arrhythmias Anemias Infectious causes CNS infections such as meningitis Encephalitis HIV-related brain infections Septicemia Pneumonia Urinary tract infections Toxic causes Substance intoxication .Delirium: [Print] . PCP. and benzodiazepines Other causes Postictal state Unfamiliar environment Operation-related delirium 7 of 20 9/6/2010 8:43 PM . and LSD Medication-induced delirium Anticholinergics (Benadryl. tricyclic antidepressants) Narcotics (meperidine) Sedative hypnotics (benzodiazepines) Histamine-2 (H2) blockers (cimetidine) Corticosteroids Centrally acting antihypertensives (methyldopa.com/article/288890-print Dysphoric mood and hopelessness are also risk factors for incident delirium.

and the patient has impaired memory and orientation and clouding of consciousness. Patients with hypoactive withdrawn delirium may be misdiagnosed as depressed. and drug-induced delirium is commonly seen in medical practice. Differential Diagnoses Depression Other Problems to Be Considered Dementia AIDS-related complex Psychosis Dementia is one of the most important risk factors for delirium. medications such as glycopyrrolate can be used because. The onset of symptoms of delirium is acute or subacute.Used to diagnose toxicological causes Thiamine and vitamin B-12 levels . anticholinergics such as atropine.eMedicine Psychiatry http://emedicine.To diagnose infection Sedimentation rate 8 of 20 9/6/2010 8:43 PM . and hyperosmolar nonketotic states Renal and liver function tests . especially in hospital settings.Helpful to diagnose infection and anemia Electrolytes . diabetic ketoacidosis.com/article/288890-print Preoperative (dementia. The risk of anticholinergic toxicity is greater in elderly persons.[21 ] Drugs are a common risk factor for delirium.To diagnose liver and renal failure Thyroid function studies . drug withdrawal) Mild cognitive impairment and vascular risk factors can be independent risk factors for postoperative delirium.To diagnose hypothyroidism Urine analysis . fluid and electrolyte imbalance) Intraoperative (meperidine. Workup Laboratory Studies Complete blood cell count with differential .To diagnose low or high levels Glucose .Used to detect deficiency states of these vitamins Tests for bacteriological and viral etiologies . Delirium may be a risk factor or marker for the development of dementia. elderly persons and in those with dementia. Depressed patients also may have cognitive symptoms.Delirium: [Print] . In delirium. and the risk of inducing delirium by medications is high in frail. The safest rule is to consider delirium when recent changes in an elderly patient's level of consciousness and cognition have occurred in an acute care setting. hypotension.To diagnose hypoglycemia. in contrast to atropine. It often coexists in patients who are hospitalized. long-acting benzodiazepines. Delirium may have to be differentiated from psychosis because both have psychotic features.Used to diagnose urinary tract infection Urine and blood drug screen .medscape. the hallucinations predominantly are visual and fluctuate. however. but the patient's level of consciousness is normal. they do not cross the blood brain barrier) Postoperative (hypoxia. polypharmacy. the patient usually does not have a previous history of serious psychiatric illness.

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. the underlying causes should be sought. Treatment Medical Care When delirium is diagnosed or suspected. Despite every effort. 9 of 20 9/6/2010 8:43 PM . Pulse oximetry is used to diagnose hypoxia as a cause of delirium. no cause for delirium can be found in a small percentage of patients. therapy should include multivitamins. The type of patterns observed includes triphasic waves in toxicity or metabolic derangement.Delirium: [Print] . hemorrhage. Electroencephalogram In delirium. Components of delirium management include supportive therapy and pharmacological management. even though 30-40% of hospitalized patients with HIV infection develop delirium during hospitalization. In patients with hepatic encephalopathy. generally. and family photos may be helpful. Environmental modifications Reorientation techniques or memory cues such as a calendar. increased EEG fast-wave activity occurs. clocks. diffuse EEG slowing occurs.com/article/288890-print Drug screen including alcohol level HIV tests Tests for other infectious causes if necessary or clinically indicated (These tests are not performed routinely. slowing of the posterior dominant rhythm and increased generalized slow-wave activity are observed on electroencephalogram (EEG) recordings. Magnetic resonance imaging (MRI) of the head may be helpful in the diagnosis of stroke. Fluid and nutrition These should be given carefully because the patient may be unwilling or physically unable to maintain a balanced intake. and structural lesions.[23 ] Imaging Studies Neuroimaging Perform CT scan of the head. especially thiamine. Higher levels are seen in patients with delirium when compared to patients without delirium. In delirium resulting from alcohol/sedative withdrawal.medscape. continuous discharges in nonconvulsive status epilepticus. and localized delta activity in focal lesions.eMedicine Psychiatry http://emedicine. Chest radiograph is used to diagnose pneumonia or congestive heart failure.[22 ]) Serum marker for delirium: The calcium-binding protein S-100 B could be a serum marker of delirium. For the patient suspected of having alcohol toxicity or alcohol withdrawal.

Older neuroleptics such as haloperidol. Perceptual problems lead to agitation. and may not be compliant. and quetiapine relieve symptoms while minimizing adverse effects. Paradoxical and hypersensitivity reactions may occur. Use lower doses in patients who are elderly. Even though case reports showed evidence that cholinesterase inhibitors may play a role in the management of delirium. Dosing Adult Moderate symptomatology: 0.Delirium: [Print] . if necessary.[24 ] Neuroleptics The medication of choice in the treatment of psychotic symptoms. and well-lighted. with eyeglasses and hearing aids.05-0. Support from a familiar nurse and family should be encouraged.25-0. and reassure the patient. quiet. Doses should be kept as low as possible to minimize adverse effects. neuroleptic malignant syndrome. change to PO therapy as soon as possible >12 years: Administer as in adults Interactions 10 of 20 9/6/2010 8:43 PM . and tardive dyskinesia. not to exceed 0. The most common medications used are neuroleptics.05 mg/kg/d or 0.com/article/288890-print The environment should be stable. olanzapine. Neuroleptics can be associated with adverse neurological effects such as extrapyramidal symptoms. Consultations Psychiatric consultation may be indicated for management of behavioral problems such as agitation or aggressive behavior. Medication Delirium that causes injury to the patient or others should be treated with medications. larger trials and systematic review did not support this use.5 mg q5-7d Maintenance dose: 0. combative behavior. Severely delirious patients benefit from constant observation (sitters). Family members and staff should explain proceedings at every opportunity. fear. are useful but have many adverse neurological effects.15 mg/kg/d.5-2 mg PO bid/tid Severe symptomatology: 3-5 mg PO bid/tid Geriatric and debilitated: 0. High-potency antipsychotic medications also cause less sedation than phenothiazines and reduce risks of exacerbating delirium.medscape. not to exceed 0. 1-2 mg IM q4-6h Pediatric <3 years: Not established 3-12 years: 0. Delirious patients may pull out intravenous lines.15 mg/kg/d PO in 2-3 divided doses. Physical restraints should be avoided.5 mg/d PO bid/tid initially and increase by 0. Attempt a trial of tapering the medication once symptoms are in control. Discontinue these medications as soon as possible.5-2 mg PO bid/tid. Haloperidol (Haldol) A butyrophenone high-potency antipsychotic.25-0.eMedicine Psychiatry http://emedicine. These patients should never be left alone or unattended. climb out of bed. Initial doses may need to be higher than maintenance doses.15 mg/kg/d 6-12 years: 1-3 mg/dose IM q4-8h. which may be cost effective for these patients and help avoid the use of physical restraints. reinforce orientation. Benzodiazepines often are used for withdrawal states. Newer neuroleptics such as risperidone. and wandering. One of most effective antipsychotics for delirium. Sensory deficits should be corrected. a high-potency antipsychotic.

coadministration with anticholinergics may increase intraocular pressure. and anesthetics Contraindications Documented hypersensitivity.Delirium: [Print] . Dosing Adult 0. if IV/IM.medscape. seizures. Parkinson disease. significant increase in body temperature may indicate intolerance to antipsychotics (discontinue if it occurs) Risperidone (Risperdal) A newer antipsychotic with fewer extrapyramidal adverse effects than Haldol.) 11 of 20 9/6/2010 8:43 PM .eMedicine Psychiatry http://emedicine. hyperprolactinemia. has potential for proarrhythmic effects by prolonging QT interval. encephalopathiclike syndrome is associated with concurrent administration with lithium. opiates. watch for hypotension. Haldol can potentiate CNS depressant effects of alcohol. severe depression. if history of seizures. may use if benefits outweigh risk to fetus Precautions Monitor for extrapyramidal symptoms (reduce dose if these occur). comatose states Precautions Pregnancy C .5-2 mg PO qd or bid 0.5 mg PO bid for elderly debilitated patients with severe renal or hepatic failure or predisposed to hypotension Pediatric Not established Interactions Coadministration with carbamazepine may decrease effects. avoid anticholinergics. phenobarbital. Improves negative symptoms of psychoses and reduces incidence of adverse extrapyramidal effects. rifampin. benefits must outweigh risks. may inhibit effects of levodopa. severe neurotoxicity manifesting as rigidity or inability to walk or talk may occur in patients with thyrotoxicosis also receiving antipsychotics. (Some studies have shown a possible increased risk of stroke.com/article/288890-print May increase tricyclic antidepressant serum concentrations and hypotensive action of antihypertensive agents. > 2 mg/d may increase adverse extrapyramidal effects in elderly patients. caution in diagnosed CNS depression or cardiac disease. and carbamazepine may decrease effects. Binds to dopamine D2-receptor with 20 times lower affinity than for 5-HT2-receptor.Fetal risk revealed in studies in animals but not established or not studied in humans. SSRIs and clozapine may increase levels Contraindications Documented hypersensitivity Precautions Pregnancy C .Fetal risk revealed in studies in animals but not established or not studied in humans. may use if benefits outweigh risk to fetus Precautions Can cause orthostatic hypotension. and body temperature regulation abnormalities.

When patient needs to be sedated for longer than 24 h. Commonly used prophylactically to prevent delirium tremens. patients who are elderly. this medication is excellent.Fetal risk shown in humans.medscape. especially in patients who are elderly. and MAOIs Contraindications Documented hypersensitivity. barbiturates. cocaine. sleep apnea syndrome. followed by 50-100 mg/d IV/IM 12 of 20 9/6/2010 8:43 PM . phenothiazines.eMedicine Psychiatry http://emedicine. or PCP toxicity. caution also needed in patients with myasthenia gravis.com/article/288890-print Short-acting sedatives Reserved for delirium resulting from seizures or withdrawal from alcohol or sedative hypnotics. or debilitated patients. Coadministration with neuroleptics is considered only in patients who tolerate lower doses of either medication or have prominent anxiety or agitation. frequent repeat dosing (q2-4h) may be needed in cases of delirium tremens Pediatric Not established Interactions Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol. Dosing Adult 0. can be used in both IM and IV forms. preexisting CNS depression. those with pulmonary problems.Delirium: [Print] . In addition. which can cause delirium. Thiamine hydrochloride (Thiamilate) For alcohol withdrawal and in cases of Wernicke encephalopathy. Use special precaution when using benzodiazepines because they may cause respiratory depression. can cause hypoxic cardiac arrest. hypotension. narrow-angle glaucoma. They also may be used when unknown substances may have been ingested and may be helpful in delirium from hallucinogen. Dosing Adult 100 mg IV initially. and very ill patients. severe respiratory insufficiency Precautions Pregnancy D .5-2 mg PO/IV/IM. Benzodiazepines are preferred over neuroleptics for treatment of delirium resulting from alcohol or sedative hypnotic withdrawal. stimulant. or Parkinson disease Vitamins Patients with alcoholism and patients with malnutrition are prone to thiamine and vitamin B-12 deficiency. Lorazepam (Ativan) Preferable because it is short acting and has no active metabolites. use only if benefits outweigh risk to fetus Precautions Caution in limited pulmonary reserve. organic brain syndrome.

hereditary optic nerve atrophy Precautions Pregnancy C . Vitamin B-12 is synthesized by microbes but not by humans or plants. Nascobal) Vitamin B-12 deficiency can cause confusion or delirium in patients who are elderly. Vitamin B-12 deficiency may result from intrinsic factor deficiency (pernicious anemia).Delirium: [Print] . then every wk for 6 mo) Pediatric 10-50 mcg/d IM for 5-10 d. administer before or together with dextrose-containing fluids in suspected thiamine deficiency Cyanocobalamin (Crystamine. hypokalemia and thrombocytosis can occur upon conversion from severe megaloblastic anemia to normal erythropoiesis after cyanocobalamin therapy. sudden onset or worsening of Wernicke encephalopathy may occur following glucose administration in patients who are thiamine-deficient.com/article/288890-print Pediatric 50 mg IV initially. partial or total gastrectomy. Dosing Adult Maintenance dose: 1000 mcg IM monthly or 500 mcg/wk intranasally or 100 mcg/d PO Load initially if deficient (100 mcg IM injections for 1 wk.Fetal risk not revealed in controlled studies in humans Precautions Sensitivity reactions can occur (intradermal test-dose recommended in suspected sensitivity). vitamin B-12 therapy can unmask polycythemia vera 13 of 20 9/6/2010 8:43 PM . Deoxyadenosylcobalamin and hydroxocobalamin are active forms of vitamin B-12 in humans.medscape. may use if benefits outweigh risk to fetus Precautions Intradermal test dose recommended before parenteral administration (anaphylactic shock and death reported with parenteral administration). monitor serum potassium levels and platelet count. followed by 10-25 mg/d IV/IM Interactions None reported Contraindications Documented hypersensitivity Precautions Pregnancy A . followed by 100-250 mcg/dose IM q2-4wk Interactions None reported Contraindications Documented hypersensitivity.eMedicine Psychiatry http://emedicine. or diseases of the distal ileum. Cyomin. deaths have resulted from IV use.Fetal risk revealed in studies in animals but not established or not studied in humans.

Complications Malnutrition. and structural brain diseases treated with large doses of psychoactive medications prior to the onset of acute medical illness. Assessment should include behavior (24 h).eMedicine Psychiatry http://emedicine. potential for injury. decreased mobility. Patients who are at high risk for delirium should be monitored closely as outpatients. family.medscape. and dehydration showed significant reduction in the number and duration of episodes of delirium in older patients who were hospitalized. keeping dosages low and avoiding medications that cause delirium.Delirium: [Print] . hearing impairment.com/article/288890-print Follow-up Further Inpatient Care Carefully assess patients to determine their level of care needs. A multicomponent intervention study that targeted cognitive impairment. and underlying medical and metabolic status. reversible acute confusion. and decreased function Falls and combative behavior leading to injuries and fractures Wandering and getting lost Long-term cognitive impairment: Accumulating evidence shows that delirium is not only a transient. Physicians should become familiar with prescribing practices for patients who are elderly. sleep deprivation. the cognitive effects of delirium may resolve slowly or not at all. and throughout surgical procedures.[25 ] Prognosis Resolution of symptoms may take longer in patients with poor premorbid cognitive function. Patient Education 14 of 20 9/6/2010 8:43 PM . immobility. Further Outpatient Care Following recovery. It is not unusual for patients who are elderly to require 6-8 weeks or longer for full recovery. but also can give rise to a persistent long-term cognitive impairment. incorrect or incomplete diagnosis of contributing factors. patient's memories of events of the delirium are variable. visual impairment. Monitoring the patient's mental status as a vital sign helps to diagnose delirium early. For some patients. during hospitalization. Deterrence/Prevention Prevention should be the goal because delirium is associated with adverse outcomes and high health care costs. and primary caregivers about future risk factors. fluid and electrolyte abnormalities Aspiration pneumonia Pressure ulcers Weakness. daily mental status. Educate the patient.

Physicians who understand the patient's medical illness and have skills in determining the patient's capacity may include psychiatrists. and geriatricians. Patient and family education materials are available here: MedlinePlus: Delirium Merck: Delirium Miscellaneous Medicolegal Pitfalls With altered mental status. Educate the patient. For example. such as durable power of attorney (DPOA) for health care decisions and living wills. Again. usually one at a time. geriatric psychiatrists. such as the capacity to make or withhold informed consent for health care or the capacity to designate a surrogate health care decision-maker. and the final authority rests with the court. Physicians should request social work assistance and consultation with hospital administrators when decision-making authority is in question.eMedicine Psychiatry http://emedicine. Immediate consultation should be sought to determine whether the patient has the capacity to understand the consequences of leaving. Ordinarily. Families may worry that the patient has brain damage or a permanent psychiatric illness. the issue is one of determining specific capacity. Precautions must be taken to prevent them from leaving the facility and becoming lost or injured. the AMA document would likely be declared invalid. a patient may be unable to understand health care options but may be quite clear and consistent on appointing a specific family member as their surrogate. Encourage them to furnish some familiar objects. Providing reassurance that delirium often is temporary and is the result of a medical condition may be beneficial to both patients and their families. such as photos or a favorite blanket. Advice is best obtained from a practitioner familiar with the laws in the patient's state.com/article/288890-print Patient and family education Educating families and patients regarding the etiology and course of disease is an important role for physicians. determining whether the patient has the capacity to make informed health care decisions is advisable.medscape. and provide a calm and structured environment. Capacity usually is not globally impaired unless delirium or depression is severe or dementia is advanced. Ascertain the existence of a legal surrogate. family. and significant liability could ensue if the patient were to leave and have an adverse outcome. The consultant makes a recommendation with regard to capacity. Explain to the family the patient's condition and the possible causes. If they do not. to help reorient the patient and make the patient feel more secure. This person should be familiar with advance directives. Assessments of capacity are best made by an objective experienced consultant who is familiar with the surrogate decision-making laws in the state. Patients with altered mental status are at high risk for elopement. which is very hard for families to appreciate and comprehend. Competence is a legal term. and primary caregivers about future risk factors. Suggest that family members or friends visit the patient. and their differing contents. Surrogate decision-making laws differ from state to state. 15 of 20 9/6/2010 8:43 PM . This is especially key because of the rapidly fluctuating mental status.Delirium: [Print] . Urgent legal assistance should be obtained to hold the patient against his or her will. hospitals and nursing homes often have administrators on call and legal consultants to help with these difficult cases. Patients with clouded sensorium may attempt to leave the hospital against medical advice (AMA).

2000(2):521-530. Neurosci Lett. Rare causes of delirium. Some examples of herbal products that have anticholinergic effects are henbane. May 20 2004. the drug that is responsible for an episode of delirium is clear because of a temporal relationship.182(5):449-54." they may contain ingredients or contaminants that can contribute to delirium. The aged blood. so the clinical effects may be greater than perceived. Unfortunately. Sometimes. Ebersoldt M. Brown LJ. [Medline]. Both the cause and symptoms of delirium should be treated. Deary IJ. Levi M. Cognitive visual perceptual deficits in patients with delirium.362(2):91-4. 6. jimson weed. While these products are considered to be "natural. 5. The use of complementary medicine is increasing in North America. In some cases.Delirium: [Print] . Boni C. 16 of 20 9/6/2010 8:43 PM . research on the adverse cognitive effects of complementary and alternative medicine products is limited. Obtaining a detailed drug history is imperative because patients may be taking over-the-counter cold and sleep medications. Intensive Care Med. Sharshar T. such as carbon monoxide poisoning. Delirium may be the only presenting symptom of an underlying medical problem. McLaren L. Kuchel GA. References 1. If not. The neuropathogenesis of delirium. Feb 2008. Chemokines are associated with delirium after cardiac surgery. Patients with infections may present without fever. should be considered. Nov 2001. Nimura Y. [Medline]. 3. [Medline]. Annane D. Starr JM.12:62-67. Rudolph JL. Facts. 2002. which are frequent causes of delirium. McGrory S. Jun 2007. et al. Shigeta H. Am J Surg. de Rooij SE. the clinician should carefully analyze the patient's history and look for a characteristic constellation of drug-related findings. [Medline]. 7. Maclullich AM.medscape. J Neurol Neurosurg Psychiatry. Sepsis-associated delirium. J Gerontol A Biol Sci Med Sci. Limosin F. Any recent addition of a new medication or increase in dose should be verified.80(6):594-9.62(5):521-5. van Munster BC. and mandrake. Banks WH. 2. J Psychosom Res. The approach to delirium has been shifted to prevention and early diagnosis and management. Cytokines and acute phase response in delirium. Research and Intervention in Geriatrics. Clinicians should be aware of medications with a significant anticholinergic effect.33(6):941-50. Yasui A.com/article/288890-print Special Concerns Subsyndromal delirium: A condition where a patient has some symptoms of delirium but does not meet the full criteria for the diagnosis of delirium. especially in people who are elderly. Korevaar JC.brain barrier: A substrate for CNS disease. In patients who develop delirium. It is also associated with longer hospital stays and require institutionalization at discharge . Postoperative delirium and melatonin levels in elderly patients. Loze JY. 4. May 2007. Hypoxemia from pulmonary edema or pulmonary embolus should be considered.63(2):184-9. The A9 allele of the dopamine transporter gene increases the risk of visual hallucinations during alcohol withdrawal in alcohol-dependent women. Rev Clin Gerontol. [Medline]. 8. Jun 2009. drugs may be the sole cause of delirium. and patients with acute stroke may present without hemiparesis. White S. a record of all medications and supplements given within the past few weeks should be carefully obtained. et al.eMedicine Psychiatry http://emedicine. et al. patients with myocardial infarction may present without chest pain. Ramlawi B. 2000. [Medline].

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medscape. Skrobik Y. Senior Pharmacy Editor. Intensive Care Med. MD. Department of Geriatrics/Gerontology. MD. Medical Director of Geriatric Psychiatry. Use of risperidone in delirium: case reports. Cosette M. Kavanagh B. and American Psychiatric Association Disclosure: Nothing to disclose. [Medline]. Gerontological Society of America. University of Hawaii Iqbal Ahmed. American Medical Directors Association. mixed delirium Contributor Information and Disclosures Author Kannayiram Alagiakrishnan. acute cognitive dysfunction. MBBS.com/article/288890-print 48. PharmD. toxic metabolic encephalopathy. Associate Professor. Pharmacy Editor Francisco Talavera. PhD. MD is a member of the following medical societies: American College of Physicians. Riker R. eMedicine Disclosure: eMedicine Salary Employment Managing Editor Iqbal Ahmed. Medical Editor Mohammed A Memon. American Neuropsychiatric Association. hyperactive delirium.33(6):1007-1013. MD. [Medline]. hypoactive delirium. pathophysiology. and American Medical Association Disclosure: Nothing to disclose. and Hawaii Medical Association Disclosure: Nothing to disclose. Sipahimalani A. John A Burns School of Medicine. Medical College of Wisconsin Harold H Harsch. John A Burns School of Medicine. and treatment.19(3):429-48. Department of Medicine. MD is a member of the following medical societies: American Psychiatric Association 19 of 20 9/6/2010 8:43 PM . Trzepacz PT. Spartanburg Regional Hospital System Mohammed A Memon. Bergeon N. American Association for Geriatric Psychiatry. Apr 3 2007. Masand PS. Ann Clin Psychiatry. Division of Geriatric Medicine. Sep 1996.eMedicine Psychiatry http://emedicine. Associate Professor. Department of Psychiatry. Subsyndromal delirium in the ICU: evidence for a disease spectrum. 49. MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine. University of Alberta Kannayiram Alagiakrishnan. Ouimet S. Department Chair and Director. Department of Psychiatry. Jun 1997. American Geriatrics Society. MBBS. Delirium. MD. and American Psychiatric Association Disclosure: Nothing to disclose.Delirium: [Print] . MD. American Geriatrics Society. MD is a member of the following medical societies: American Association for Geriatric Psychiatry. Keywords acute confusional state. Psychiatr Clin North Am. Geriatric Medicine. American Medical Association. 50. Advances in diagnosis. Geriatric Medicine Fellowship Program. Froedtert Hospital. CME Editor Harold H Harsch.9(2):105-7. Professor. Professor of Geriatric Medicine. University of Hawaii Patricia Blanchette. Program Director of Geropsychiatry. MBBS is a member of the following medical societies: American College of Physicians. [Medline]. American Medical Association. Coauthor(s) Patricia Blanchette. Department of Psychiatry and Department of Medicine.

Otsuke Grant/research funds reseach.com/public/copyright) 20 of 20 9/6/2010 8:43 PM . Pfizer Honoraria Speaking and teaching.medscape. Further Reading © 1994-2010 by Medscape. Novartis Grant/research funds research. President of Education Initiatives. MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society Disclosure: Nothing to disclose. GlaxoSmithKline Grant/research funds research. All Rights Reserved (http://www. Boston. Forest Labs Honoraria Speaking and teaching.medscape.com/article/288890-print Disclosure: lilly Honoraria Speaking and teaching. Nottingham. Pfizer Grant/research funds Speaking and teaching. NH.Delirium: [Print] . Metropolitan College of Boston University. Northstar Grant/research funds Research. Faculty. Sanofi-avetis research. Merck Honoraria None Chief Editor Stephen Soreff. MA Stephen Soreff. MD.eMedicine Psychiatry http://emedicine.