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Delirium di-!lir-E-um

by Juebin Huang, MD, PhD

Delirium is a sudden, fluctuating, and usually reversible disturbance of mental function. It is characterized by an inability to pay attention, disorientation, an inability to think clearly, and fluctuations in the level of alertness (consciousness).

  • Many disorders and drugs can cause delirium.

  • Doctors base the diagnosis on symptoms and results of a physical examination, and they use blood, urine, and imaging tests to identify the cause.

  • Promptly correcting or treating the condition causing delirium usually cures it.

Delirium is an abnormal mental state, not a disease. Although the term has a specific medical definition, it is often used to describe any type of confusion. Delirium is never normal and often indicates a usually serious, newly developed problem, especially in older people. People who have delirium need immediate medical attention. If the cause of delirium is identified and corrected quickly, delirium can usually be cured.

Because delirium is a temporary condition, determining how many people have it is difficult. Delirium affects 15 to 50% of hospitalized people aged 70 or older.

Delirium may occur at any age but is more common among older people. Delirium is common among residents of nursing homes. When delirium occurs in younger people, it is usually due to drug use or a life-threatening disorder.

Causes

Development or worsening of many disorders can cause delirium. Any person can become delirious when extremely ill or taking drugs that affect brain function (psychoactive drugs). However, delirium can result from less severe conditions in older people and in people who have had a stroke or who have dementia, Parkinson disease, or another disorder that causes nerve degeneration. In these people, a relatively minor problem can trigger delirium. These problems include minor illnesses (such as a urinary tract infection), severe constipation, pain, use of a bladder catheter (a thin tube used to drain urine from the bladder), dehydration, prolonged sleep deprivation, and sensory deprivation (including being socially isolated or not having access to needed eyeglasses or hearing aids). In some people, no cause can be identified.

Hospitalization

Being in the hospital, particularly in an intensive care unit (ICU), can contribute to or trigger delirium. In ICUs, people are isolated in a room that typically has no windows or clocks. Thus, people are deprived of normal sensory stimulation and can become disoriented. Sleep is disturbed by staff members who awaken people during the night to monitor and treat them and by loud beeping monitors, intercoms, voices in the hallway, or alarms. Furthermore, most people in ICUs have serious disorders and are treated with drugs, which can make delirium even more likely. The delirium that may result is sometimes called ICU psychosis.

Surgery

Delirium is also very common after surgery, probably because of the stress of surgery, the anesthetics used during surgery, and the pain relievers (analgesics) used after surgery.

Drug use

The most common reversible cause of delirium is drugs. In younger people, using illegal drugs and acute intoxication with alcohol are common causes. In older people, prescription drugs are usually the cause.

Psychoactive drugs directly affect nerve cells in the brain, sometimes causing delirium. They include the following:

  • Opioids (including morphine and meperidine)

  • Sedatives (including benzodiazepines and sleep aids)

  • Antipsychotics

  • Antidepressants

Many other drugs can also cause delirium. The following are some examples:

  • Drugs with anticholinergic effects (see Anticholinergic: What Does It Mean?), including many over-the-counter (OTC) antihistamines

  • Amphetamines and cocaine, which are stimulants

  • Cimetidine

  • Corticosteroids

  • Digoxin

  • Levodopa

  • Muscle relaxants

Drug withdrawal

Delirium can also result from suddenly stopping a drug that has been taken for a long time—for example, a sedative (such as a benzodiazepine or barbiturate) or an opioid pain reliever. Delirium commonly occurs in alcoholics who suddenly stop drinking alcohol (see Drug Use and Abuse:Withdrawal Symptoms) and in heroin users who suddenly stop using heroin.

Disorders

Abnormal blood levels of electrolytes, such as calcium, sodium, or magnesium, can interfere with the metabolic activity of nerve cells and lead to delirium. Abnormal electrolyte levels may result from use of a diuretic, dehydration, or disorders such as kidney failure and widespread cancer. Blood sugar levels that are extremely high (hyperglycemia) or low (hypoglycemia) commonly cause delirium. An underactive thyroid gland (hypothyroidism) causes delirium with sluggishness (lethargy). An overactive thyroid gland (hyperthyroidism) causes delirium with hyperactivity.

If liver or kidney failure develops and is not diagnosed, a drug that a person has been taking for a long time can cause delirium, even though it previously caused no problems. In these disorders, the liver or kidneys do not process and eliminate drugs normally. As a result, drugs may accumulate in the blood and reach the brain, causing delirium.

In younger people (once drugs and alcohol are excluded), the cause of delirium is usually a condition that directly affects the brain—for example, a brain infection, such as meningitis or encephalitis. In older people, the cause is often a common infection, such as a urinary tract infection, pneumonia, or influenza. Such infections can indirectly affect the brain.

Wernicke encephalopathy (see Wernicke’s Encephalopathy), which results from by a severe deficiency of the B vitamin thiamin, can cause confusion and delirium. If untreated, Wernicke encephalopathy can cause severe brain damage, coma, or death.

Poisons

In younger people, ingestion of poisons, such as rubbing alcohol or antifreeze, is a common cause of delirium.

Symptoms

Delirium usually begins suddenly and progresses over hours or days. The actions of people with delirium vary but roughly resemble those of a person who is becoming progressively more intoxicated.

The hallmark of delirium is an inability to pay attention. People with delirium cannot concentrate, so they have trouble processing new information and cannot recall recent events. Thus, they do not understand what is happening around them. They become disoriented. Sudden confusion about time and often about place (where they are) may be an early sign of delirium. If delirium is severe, people may not know who they or other people are. Thinking is confused, and people with delirium ramble, sometimes becoming incoherent. Their level of awareness (consciousness) may fluctuate. That is, people may be overly alert one moment and drowsy and sluggish the next. Other symptoms also often change within minutes and tend to worsen during the evening (a phenomenon called sundowning). People with delirium often sleep restlessly or reverse their sleep-wake cycle, sleeping during the day and staying awake at night.

People may have bizarre, frightening visual hallucinations, seeing things or people that are not there. Some people develop paranoia or have delusions (false beliefs usually involving a misinterpretation of perceptions or experiences).

Personality and mood may change. Some people become so quiet and withdrawn that no one notices that they are delirious. Others become irritable, agitated, and restless and may pace. People who develop delirium after taking sedatives are likely to become very drowsy and withdrawn. Those who have taken amphetamines or who have stopped taking sedatives may become aggressive and hyperactive. Some people alternate between the two types of behavior.

Delirium can last hours, days, or even longer, depending on the severity and the cause. If the cause of delirium is not quickly identified and treated, people may become increasingly drowsy and unresponsive, requiring vigorous stimulation to be aroused (a condition called stupor—see see Stupor and Coma). Stupor may lead to coma or death.

Did You Know...

  • A psychosis that begins during old age usually indicates delirium or dementia.

Diagnosis

Doctors suspect delirium based on symptoms, particularly when people cannot pay attention and when their ability to pay attention fluctuates from one moment to the next. However, mild delirium may be difficult to recognize. Doctors may not recognize delirium in hospitalized people.

Most people thought to have delirium are hospitalized to evaluate them and protect them from injuring themselves or others. Diagnostic procedures can be done quickly and safely in the hospital, and any disorders detected can be treated quickly.

Because delirium may be caused by a serious disorder (which could be rapidly fatal), doctors try to identify the cause as quickly as possible. Treating the cause, once identified, can often reverse the delirium.

Doctors first try to distinguish delirium from other disorders that affect mental function. Doctors do so by collecting as much information about the person’s medical history as possible, by doing a physical examination, and by testing.

Medical history

Friends, family members, or other observers are asked for information because people with delirium are usually unable to answer. Questions include the following:

  • How the confusion began (suddenly or gradually)

  • How quickly it progressed

  • What has the person’s physical and mental health been like

  • What drugs (including alcohol and illicit drugs, especially if the person is younger) and dietary supplements does the person use

  • Whether any drugs have been started or stopped recently

Information may also come from medical records, the police, emergency medical personnel, or evidence such as pill bottles and certain documents. Documents such as a checkbook, recent letters, or notification of unpaid bills or missed appointments can indicate a change in mental function.

If delirium is accompanied by agitation and hallucinations, delusions, or paranoia, it must be distinguished from a psychosis due to a psychiatric disorder, such as manic-depressive illness or schizophrenia. People with a psychosis due to a psychiatric disorder do not have confusion or memory loss, and the level of consciousness does not change. A psychosis that begins during old age usually indicates delirium or dementia.

Delirium or Psychosis?

Feature

Delirium

Psychosis Due to a Psychiatric Disorder

Orientation

Confused about current time, date, place, or identity

Usually, aware of time, date, place, and identity

Attention

Greatly impaired

Unaffected

Memory for recent events

Lost

Retained

Ability to calculate

Unable to do simple calculations

Retained

Hallucinations

If present, mostly visual or involving touch

If present, mostly auditory

Other disorders

Often present and may be serious

History of previous psychiatric disturbances

Drug use

Often, evidence of recent drug use

Not necessarily involved

Physical examination

During the physical examination, doctors check for signs of disorders that can cause delirium, such as infections and dehydration. A neurologic examination is also done (see Introduction to Symptoms and Diagnosis of Brain, Spinal Cord, and Nerve Disorders). People who may have delirium are given a mental status test (see Mental status). First, they are asked questions to determine whether the main problem is being unable to pay attention. For example, they are read a short list and asked to repeat it. Doctors must determine whether people take in (register) what is read to them. People with delirium cannot. The test also includes other questions and tasks, such as testing short-term and long-term memory, naming objects, writing sentences, and copying shapes.

Testing

Samples of blood and urine are usually taken and analyzed to check for disorders that doctors think may be causing delirium. For example, abnormalities in electrolyte and blood sugar levels and liver and kidney disorders are common causes of delirium. So doctors usually do blood tests to measure electrolyte and blood sugar levels and to evaluate how well the liver and kidneys are functioning. If doctors suspect a thyroid disorder, tests may be done to evaluate how well the thyroid gland is functioning. Or if doctors suspect that certain drugs may be the cause, they may do tests to measure drug levels in the blood. These tests can help determine whether drug levels are high enough to have harmful effects and whether a person took an overdose.

Cultures may be done to look for infections. Computed tomography (CT) or magnetic resonance imaging (MRI) of the brain is usually done. Sometimes a test that records the brain's electrical activity (electroencephalography, or EEG) is done to determine whether the delirium is caused by a seizure disorder. Electrocardiography (ECG), pulse oximetry (using a sensor that measures oxygen levels in the blood), and a chest x-ray may be used to evaluate how well the heart and lungs are functioning.

In people with a fever or headache, a spinal tap (lumbar puncture—see see Figure: ) may be done to obtain cerebrospinal fluid for analysis. Such analysis helps doctors rule out infection of or bleeding around the brain and spinal cord.

Treatment

Most people who have delirium are hospitalized. However, when the cause of delirium can be corrected readily (for example, when the cause is low blood sugar), people are observed for a short time in the emergency department and can then return home.

Once the cause is identified, it is promptly corrected or treated. For example, doctors treat infections with antibiotics, dehydration with fluids and electrolytes given intravenously, and delirium due to stopping alcohol with benzodiazepines (as well as measures to help people not start drinking alcohol again). Prompt treatment of the disorder causing delirium usually prevents permanent brain damage and may result in a complete recovery. Any drugs that may be making the delirium worse are stopped if possible.

General measures are also important. The environment is kept as quiet and calm as possible. It should be well-lit to enable people to recognize what and who is in their room and where they are. Placing clocks, calendars, and family photographs in the room can help with orientation. At every opportunity, staff and family members should reassure people and remind them of the time and place. Procedures should be explained before and as they are done. People who need glasses or hearing aids should have access to them.

People who have delirium are prone to many problems, including dehydration, undernutrition, incontinence, falls, and pressure sores. Preventing such problems requires meticulous care. Thus, people, particularly older people, may benefit from treatment managed by an interdisciplinary team, which includes a doctor, physical and occupational therapists, nurses, and social workers.

People who are extremely agitated or who have hallucinations may injure themselves or their caregivers. The following measures can help prevent such injuries:

  • Family members are encouraged to stay with the person.

  • The person is put in a room near the nurses’ station.

  • The hospital may provide an attendant to stay with the person.

  • Devices, such as intravenous lines, bladder catheters, or padded restraints, are not used if possible because they can further confuse and upset the person, increasing the risk of injury.

However, sometimes during hospitalization, padded restraints must be used—for example, to keep the person from pulling out intravenous lines and to prevent falls. Restraints are applied carefully by a staff member trained in their use, released at frequent intervals, and stopped as soon as possible because they can upset the person and worsen agitation.

For agitation, drugs are used only after all other measures have been ineffective. Two types of drugs are usually used to control agitation, but neither is ideal:

  • Antipsychotic drugs (see Table: Antipsychotic drugs) are most often used. However, they may prolong or worsen agitation, and some have anticholinergic effects, including confusion, blurred vision, constipation, dry mouth, light-headedness, difficulty starting and continuing to urinate, and loss of bladder control (see Anticholinergic: What Does It Mean?). Newer antipsychotics, such as risperidone, have fewer side effects than older antipsychotics, such as haloperidol. But if used for a long time in people with dementia, the newer drugs may increase the risk of stroke and death.

  • Benzodiazepines (a type of sedative—see see Treatment and see Table: Drugs Used to Treat Anxiety Disorders), such as lorazepam, are used when delirium is due to withdrawal from a sedative or alcohol. Benzodiazepines are not used to treat delirium caused by other conditions because they can make people, particularly older people, more confused, drowsy, or both.

Doctors are careful when prescribing these drugs, particularly for older people. They use the lowest dose possible and stop the drug as soon as possible.

Prognosis

Most people recover fully if the condition causing delirium is rapidly identified and treated. Any delay decreases the chance of a full recovery. Even when delirium is treated, some symptoms may persist for many weeks or months, and improvement may occur slowly. In some people, delirium evolves into chronic brain dysfunction similar to dementia.

Hospitalized people who have delirium are up to 10 times more likely to develop complications in the hospital (including death) than those who do not have delirium. About 35 to 40% of people who have delirium while in a hospital die within 1 year. Hospitalized people who have delirium, particularly older people, have a longer hospital stay, higher treatment costs, and a longer recovery time after they leave the hospital.

Resources In This Article

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • LANOXIN
  • DEMEROL
  • DURAMORPH PF, MS CONTIN
  • TAGAMET
  • HALDOL
  • RISPERDAL
  • ATIVAN