Delirium: [Print] - eMedicine Psychiatry

http://emedicine.medscape.com/article/288890-print

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

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

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

is associated with increased vulnerability to delirium.medscape.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. Medications are the most common reversible cause of delirium. and the physician treating the delirium should investigate each cause contributing to it. delirium is multifactorial in etiology. such as sensory deprivation. 6 of 20 9/6/2010 8:43 PM . The presence of dementia increases the risk of delirium 2-3 times. Another instrument that can be used in ICU settings is the Intensive Care Delirium Screening Checklist (ICDSC).Delirium: [Print] . 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. Although numerous risk factors have been described. sleep deprivation. 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. fecal impaction. a recent study identified 5 important independent risk factors. and change of environment In persons who are elderly. especially patients on mechanical ventilation.eMedicine Psychiatry http://emedicine. Underlying dementia is observed in 25-50% of patients. or medication can cause delirium. intoxication. which may be an indicator of low cognitive reserve. The severity of delirium in the ICU can be estimated by the Delirium Detection Scale (DDS). Often. medications at therapeutic doses and levels can cause delirium. Low educational level. Causes Almost any medical illness. The CAM-ICU makes use of nonverbal assessments to evaluate the important features of delirium. urinary retention.

such as cerebral infarction. subarachnoid hemorrhage.Delirium: [Print] . opioids. PCP. acid-base disturbances. tricyclic antidepressants) Narcotics (meperidine) Sedative hypnotics (benzodiazepines) Histamine-2 (H2) blockers (cimetidine) Corticosteroids Centrally acting antihypertensives (methyldopa.medscape. and benzodiazepines Other causes Postictal state Unfamiliar environment Operation-related delirium 7 of 20 9/6/2010 8:43 PM . and hypertensive encephalopathy Primary or metastatic brain tumors Brain abscess Metabolic causes Fluid and electrolyte abnormalities. 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 .eMedicine Psychiatry http://emedicine. Structural changes Closed head injury or cerebral hemorrhage Cerebrovascular accidents.com/article/288890-print Dysphoric mood and hopelessness are also risk factors for incident delirium. heroin. and LSD Medication-induced delirium Anticholinergics (Benadryl. reserpine) Anti-Parkinson drugs (levodopa) Substance withdrawal from alcohol. cannabis.Alcohol.

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

increased EEG fast-wave activity occurs. In patients with hepatic encephalopathy. Pulse oximetry is used to diagnose hypoxia as a cause of delirium. Fluid and nutrition These should be given carefully because the patient may be unwilling or physically unable to maintain a balanced intake. The type of patterns observed includes triphasic waves in toxicity or metabolic derangement. therapy should include multivitamins. even though 30-40% of hospitalized patients with HIV infection develop delirium during hospitalization.Delirium: [Print] . Components of delirium management include supportive therapy and pharmacological management. hemorrhage. Magnetic resonance imaging (MRI) of the head may be helpful in the diagnosis of stroke. diffuse EEG slowing occurs.[23 ] Imaging Studies Neuroimaging Perform CT scan of the head. slowing of the posterior dominant rhythm and increased generalized slow-wave activity are observed on electroencephalogram (EEG) recordings. Despite every effort.medscape.[22 ]) Serum marker for delirium: The calcium-binding protein S-100 B could be a serum marker of delirium. Treatment Medical Care When delirium is diagnosed or suspected. Environmental modifications Reorientation techniques or memory cues such as a calendar. Electrocardiogram is used to diagnose ischemic and arrhythmic causes. no cause for delirium can be found in a small percentage of patients. 9 of 20 9/6/2010 8:43 PM . and structural lesions. Electroencephalogram In delirium. generally. clocks. and family photos may be helpful. Higher levels are seen in patients with delirium when compared to patients without delirium. the underlying causes should be sought.eMedicine Psychiatry http://emedicine. Chest radiograph is used to diagnose pneumonia or congestive heart failure. For the patient suspected of having alcohol toxicity or alcohol withdrawal. continuous discharges in nonconvulsive status epilepticus. especially thiamine. 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. In delirium resulting from alcohol/sedative withdrawal. and localized delta activity in focal lesions.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.

5-2 mg PO bid/tid. and well-lighted. a high-potency antipsychotic. Paradoxical and hypersensitivity reactions may occur. Severely delirious patients benefit from constant observation (sitters).5-2 mg PO bid/tid Severe symptomatology: 3-5 mg PO bid/tid Geriatric and debilitated: 0. Newer neuroleptics such as risperidone. Attempt a trial of tapering the medication once symptoms are in control.05 mg/kg/d or 0. and tardive dyskinesia. olanzapine. 1-2 mg IM q4-6h Pediatric <3 years: Not established 3-12 years: 0. if necessary. Initial doses may need to be higher than maintenance doses.15 mg/kg/d PO in 2-3 divided doses. Family members and staff should explain proceedings at every opportunity. fear. Sensory deficits should be corrected.05-0. Physical restraints should be avoided. and reassure the patient.[24 ] Neuroleptics The medication of choice in the treatment of psychotic symptoms.5 mg/d PO bid/tid initially and increase by 0.15 mg/kg/d. with eyeglasses and hearing aids.5 mg q5-7d Maintenance dose: 0. Use lower doses in patients who are elderly.eMedicine Psychiatry http://emedicine. Perceptual problems lead to agitation. Even though case reports showed evidence that cholinesterase inhibitors may play a role in the management of delirium.15 mg/kg/d 6-12 years: 1-3 mg/dose IM q4-8h. combative behavior. not to exceed 0.25-0. Neuroleptics can be associated with adverse neurological effects such as extrapyramidal symptoms. which may be cost effective for these patients and help avoid the use of physical restraints. 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 may not be compliant. are useful but have many adverse neurological effects.Delirium: [Print] . Haloperidol (Haldol) A butyrophenone high-potency antipsychotic. Doses should be kept as low as possible to minimize adverse effects. Support from a familiar nurse and family should be encouraged. and quetiapine relieve symptoms while minimizing adverse effects. These patients should never be left alone or unattended. larger trials and systematic review did not support this use. Medication Delirium that causes injury to the patient or others should be treated with medications.medscape. High-potency antipsychotic medications also cause less sedation than phenothiazines and reduce risks of exacerbating delirium.25-0. The most common medications used are neuroleptics. Consultations Psychiatric consultation may be indicated for management of behavioral problems such as agitation or aggressive behavior. Older neuroleptics such as haloperidol. not to exceed 0. Benzodiazepines often are used for withdrawal states. reinforce orientation. One of most effective antipsychotics for delirium. and wandering. Discontinue these medications as soon as possible. Delirious patients may pull out intravenous lines.com/article/288890-print The environment should be stable. Dosing Adult Moderate symptomatology: 0. neuroleptic malignant syndrome. quiet. climb out of bed.

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

caution also needed in patients with myasthenia gravis.medscape.5-2 mg PO/IV/IM. In addition. or debilitated patients. organic brain syndrome. hypotension.Delirium: [Print] . severe respiratory insufficiency Precautions Pregnancy D . or Parkinson disease Vitamins Patients with alcoholism and patients with malnutrition are prone to thiamine and vitamin B-12 deficiency. Coadministration with neuroleptics is considered only in patients who tolerate lower doses of either medication or have prominent anxiety or agitation. especially in patients who are elderly. and MAOIs Contraindications Documented hypersensitivity. followed by 50-100 mg/d IV/IM 12 of 20 9/6/2010 8:43 PM . preexisting CNS depression.eMedicine Psychiatry http://emedicine. can cause hypoxic cardiac arrest. which can cause delirium. Commonly used prophylactically to prevent delirium tremens. and very ill patients. this medication is excellent. Lorazepam (Ativan) Preferable because it is short acting and has no active metabolites. When patient needs to be sedated for longer than 24 h. patients who are elderly. They also may be used when unknown substances may have been ingested and may be helpful in delirium from hallucinogen. or PCP toxicity. stimulant. Benzodiazepines are preferred over neuroleptics for treatment of delirium resulting from alcohol or sedative hypnotic withdrawal. Thiamine hydrochloride (Thiamilate) For alcohol withdrawal and in cases of Wernicke encephalopathy. those with pulmonary problems.com/article/288890-print Short-acting sedatives Reserved for delirium resulting from seizures or withdrawal from alcohol or sedative hypnotics. cocaine. sleep apnea syndrome. Use special precaution when using benzodiazepines because they may cause respiratory depression. 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. use only if benefits outweigh risk to fetus Precautions Caution in limited pulmonary reserve. phenothiazines. narrow-angle glaucoma. can be used in both IM and IV forms. barbiturates.Fetal risk shown in humans. Dosing Adult 0. Dosing Adult 100 mg IV initially.

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

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

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

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

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

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

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