History

Fact Explanation
Difficulty maintaining or shifting attention Delirium is a clinical syndrome characterized by impairment of focused attention and disturbances of consciousness. [1]
Clouding of consciousness There is an acute change of consciousness, most times this complaint is brought forth by the patient's family or hospital staff. They present with fluctuating levels of consciousness and periodically falling asleep. [2]
Agitation This is one of the commonest symptoms of presentation. Usually agitation is a result of disorientation and confusion. [2]
Sleep disturbance Delirium presents with varying degrees of reversal of the sleep-wake cycle. They may periodically fall asleep during the day and then be awake for several hours during the night. Usually combined with confusion; disorientation and environmental factors such as hospital stay may worsen this symptom. Studies have revealed that sleep and delirium coexist and both can cause or worsen the other. [1][3][4]
Behavioural changes Patients show variable levels of behavioral changes including aggressiveness, apathy, withdrawal etc. Studies have shown that elderly patients with delirium may only exhibit behavioral change. [1][8]
Perceptional disturbances Delirum is associated with delusions and hallucination . Visual hallucinations are more prominent in alcohol related delirium. Delusions are more related to the memory impairment and disorientation, than a psychotic pathology. [2][6]
Neurological symptoms: Dysphasia Dysarthria,Tremor,Asterixis in hepatic encephalopathy ,uremia, Motor abnormalities Several neurological symptoms as well as signs are seen in delirium, regardless of the cause. [2][1][7]
Apathy and withdrawal Present in patients with hypoactive delirium. They are appear to be depressed due to blunted mood, exhibit lack of interaction and response. [2]
Disorientation Disorientation in date, time, place and person can occur. Usually coexists with memory impairment and confusion. [1][2][5]
References
  1. FONG TG, TULEBAEV SR, INOUYE SK. Delirium in elderly adults: diagnosis, prevention and treatment Nat Rev Neurol [online] 2009 Apr, 5(4):210-220 [viewed 29 May 2014] Available from: doi:10.1038/nrneurol.2009.24
  2. ONDRIA C. GLEASON,Delirium,Am Fam Physician[online]. 2003 Mar 1;67(5):1027-1034.[viewed 29 May 2014] Available from:http://www.aafp.org/afp/2003/0301/p1027.html
  3. WATSON PL, CERIANA P, FANFULLA F. DELIRIUM: IS SLEEP IMPORTANT? Best Pract Res Clin Anaesthesiol [online] 2012 Sep, 26(3):10.1016/j.bpa.2012.08.005 [viewed 29 May 2014] Available from: doi:10.1016/j.bpa.2012.08.005
  4. LOMBARDI C, ROCCHI R, MONTAGNA P, SILANI V, PARATI G. Obstructive Sleep Apnea Syndrome: A Cause of Acute Delirium J Clin Sleep Med [online] 2009 Dec 15, 5(6):569-570 [viewed 29 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2792974
  5. KAPLAN PW. Delirium and epilepsy Dialogues Clin Neurosci [online] 2003 Jun, 5(2):187-200 [viewed 29 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181626
  6. HAUDHURY S. Hallucinations: Clinical aspects and management Ind Psychiatry J [online] 2010, 19(1):5-12 [viewed 29 May 2014] Available from: doi:10.4103/0972-6748.77625
  7. TARGUM SD. Treating Psychotic Symptoms in Elderly Patients Prim Care Companion J Clin Psychiatry [online] 2001, 3(4):156-163 [viewed 29 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181181
  8. WASS S, WEBSTER PJ, NAIR BR. Delirium in the Elderly: A Review Oman Med J [online] 2008 Jul, 23(3):150-157 [viewed 02 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3282320

Examination

Fact Explanation
GCS assessment: Low or normal Delirium presents with confusion and fluctuating levels of consciousness. In an acute setting, GCS assessment is a must in order to evaluate, monitor and mange the patient. [5],[6]
General examination: Low blood pressure Can lead to to cerebral hypo-perfusion, causing symptoms of delirium. [1][2]
General examination: Elevated body temperature and neck stiffeness Sepsis or infections commonly cause delirium especially in the elderly (urinary tract infections and respiratory tract infections are common). [1],[2] Fever associated with neck stiffness is suggestive of meningeal involvement.
General examination: Skin turgor/dry skin Dehydration is a widely known risk factor for delirium in the elderly. [3],[4]
Neurological examination: neck stiffness, focal neurological signs Direct neurological injury can also cause delirium. [9],[10]
Mental State Examination (MSE) : Appearance is restless, agitated or may appear drowsy and fearful. Patients are confused and disoriented. Agitation is a common presentation. Due to disturbed sleep wake cycle or due to sedatives patient may appear drowsy. [7],[9]
MSE: Speech is incoherent Confusion, drowsiness or disorientation can make the patient incoherent. [7],[8]
MSE : Mood is anxious or fearful Anxiety or fear can be a result of the acute confessional state. [7]
MSE: Thoughts are muddled and incoherent Muddled thoughts/disturbed thoughts are features of delirium. [7],[10]
MSE: Perceptions - illusions, visual and auditory hallucinations Perceptional abnormalities, specially visual hallucinations are common.[7]
MSE: Cognitive functions- impaired , reduced attention, disoriented, impaired ability to recall and concentrate Acute impairment of consciousness is a main feature. [7] Impaired attention and concentration are easily demonstrable, this could be done by asking the patient to recite the days of the week backwards (or months of the year). Another test is the serial sevens test (counting backwards from one hundred deducting seven each time). The patient is disoriented in time, place and person. [7],[9] Reduced attention and concentration leads to impaired short term memory. Can be demonstrated by asking the patient to memorize five items and to recall them after five minutes, alternatively an address with five different components can be recalled. [7],[10],[11]
References
  1. TAKEUCHI A, AHERN TL, HENDERSON SO. Excited Delirium West J Emerg Med [online] 2011 Feb, 12(1):77-83 [viewed 02 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088378
  2. ELIE M, COLE MG, PRIMEAU FJ, BELLAVANCE F. Delirium Risk Factors in Elderly Hospitalized Patients J Gen Intern Med [online] 1998 Mar, 13(3):204-212 [viewed 02 June 2014] Available from: doi:10.1046/j.1525-1497.1998.00047.x
  3. FONG TG, TULEBAEV SR, INOUYE SK. Delirium in elderly adults: diagnosis, prevention and treatment Nat Rev Neurol [online] 2009 Apr, 5(4):210-220 [viewed 02 June 2014] Available from: doi:10.1038/nrneurol.2009.24
  4. POPKIN BM, D’ANCI KE, ROSENBERG IH. Water, Hydration and Health Nutr Rev [online] 2010 Aug, 68(8):439-458 [viewed 02 June 2014] Available from: doi:10.1111/j.1753-4887.2010.00304.x
  5. MCPHERSON JA, WAGNER CE, BOEHM LM, HALL JD, JOHNSON DC, MILLER LR, BURNS KM, THOMPSON JL, SHINTANI AK, ELY EW, PANDHARIPANDE PP. Delirium in the Cardiovascular Intensive Care Unit: Exploring Modifiable Risk Factors Crit Care Med [online] 2013 Feb, 41(2):405-413 [viewed 02 June 2014] Available from: doi:10.1097/CCM.0b013e31826ab49b
  6. STERN TA, CELANO CM, GROSS AF, HUFFMAN JC, FREUDENREICH O, KONTOS N, NEJAD SH, REPPER-DELISI J, THOMPSON BT. The Assessment and Management of Agitation and Delirium in the General Hospital Prim Care Companion J Clin Psychiatry [online] 2010, 12(1):PCC.09r00938 [viewed 02 June 2014] Available from: doi:10.4088/PCC.09r00938yel
  7. ONDRIA C. GLEASON,Delirium,Am Fam Physician[online]. 2003 Mar 1;67(5):1027-1034.[viewed 02 June 2014] Available from:http://www.aafp.org/afp/2003/0301/p1027.html
  8. GOWER LE, GATEWOOD MO, KANG CS. Emergency Department Management of Delirium in the Elderly West J Emerg Med [online] 2012 May, 13(2):194-201 [viewed 02 June 2014] Available from: doi:10.5811/westjem.2011.10.6654
  9. MARCIA O. MILLER,Evaluation and Management of Delirium in Hospitalized Older Patients,Am Fam Physician[online]. 2008 Dec 1;78(11):1265-1270.[viewed 02 June 2014] Available from:http://www.aafp.org/afp/2008/1201/p1265.html
  10. ROBINSON TN, EISEMAN B. Postoperative delirium in the elderly: diagnosis and management Clin Interv Aging [online] 2008 Jun, 3(2):351-355 [viewed 02 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546478
  11. RUDOLPH JL, JONES RN, GRANDE LJ, MILBERG WP, KING EG, LIPSITZ LA, LEVKOFF SE, MARCANTONIO ER. Impaired Executive Function Is Associated with Delirium After Coronary Artery Bypass Graft Surgery J Am Geriatr Soc [online] 2006 Jun, 54(6):937-941 [viewed 03 June 2014] Available from: doi:10.1111/J.1532-5415.2006.00735.X

Differential Diagnoses

Fact Explanation
Dementia in the elderly dementia is a main differential diagnosis for delirium. Disorientation , agitation and memory impairment are common in both, but delirium has more acute onset in comparison to the gradual deterioration of dementia. Memory impairment is more significant in dementia. Though disorientation characteristic in delirium it can also occur in latter stage of dementia. Visual hallucinations are a common feature of delirium, but not seen in dementia. Importantly in delirium symptoms fluctuate and worsen at night. Superimposed delirium can co-exist with dementia, this leads to poor outcome. [1],[2],[3]
Psychotic illness Patients with psychotic illness can present with agitation, confusion and perceptional abnormalities . However, in delirium there may be evidence of physical illness such as fever, fits or other neurological symptoms. Mental state examination findings of visual hallucination is more towards delirium. Deficit in reality, previous history of psychiatric disorder, auditory hallucinations, well formed delusions and disinhibition are in favor of a psychotic illness. [1],[4],[5]
Intoxication with psychoactive substance such as alcohol or amphetamines Restlessness and agitation are seen in intoxication of alcohol. Smell of alcohol, positive breathalyzer test and blood alcohol level will point to a diagnosis of alcohol intoxication . Though visual hallucinations of animals are characteristic of alcohol intoxication, visual and auditory hallucinations are also common in delirium. [6],[7]
Depression Hypoactive delirium and depression both are characterized by apathy, withdrawal and sleep disturbances. Feelings of hopelessness and worthlessness; thoughts of suicide are more suggestive of depressive episodes. In delirium, acute onset and fluctuating symptoms are characteristic. Usually depression presents in recurrent episodes or in chronic cases there may be a significant past psychiatric history. [1]
References
  1. ONDRIA C. GLEASON,Delirium,Am Fam Physician[online]. 2003 Mar 1;67(5):1027-1034.[viewed 29 May 2014] Available from:http://www.aafp.org/afp/2003/0301/p1027.html
  2. FONG TG, TULEBAEV SR, INOUYE SK. Delirium in elderly adults: diagnosis, prevention and treatment Nat Rev Neurol [online] 2009 Apr, 5(4):210-220 [viewed 29 May 2014] Available from: doi:10.1038/nrneurol.2009.24
  3. FICK DM, HODO DM, LAWRENCE F, INOUYE SK. Recognizing Delirium Superimposed on Dementia: Assessing Nurses’ Knowledge Using Case Vignettes J Gerontol Nurs [online] 2007 Feb, 33(2):40-49 [viewed 29 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2247368
  4. TARGUM SD. Treating Psychotic Symptoms in Elderly Patients Prim Care Companion J Clin Psychiatry [online] 2001, 3(4):156-163 [viewed 29 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181181
  5. MARCIA O. MILLER,Evaluation and Management of Delirium in Hospitalized Older Patients, Am Fam Physician[online]. 2008 Dec 1;78(11):1265-1270.[viewed 29 May 2014] Available from: http://www.aafp.org/afp/2008/1201/p1265.html
  6. SAMUEL E, WILLIAMS RB, FERRELL RB. Excited delirium: Consideration of selected medical and psychiatric issues Neuropsychiatr Dis Treat [online] 2009:61-66 [viewed 29 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695211
  7. TAKEUCHI A, AHERN TL, HENDERSON SO. Excited Delirium West J Emerg Med [online] 2011 Feb, 12(1):77-83 [viewed 29 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088378

Investigations - for Diagnosis

Fact Explanation
Full blood count Anemia is a causative factor for delirium, especially a hemoglobin level less than 10 g per dL.
Serum electrolytes Electrolyte abnormalities and dehydration can cause delirium. [1]
Erythrocyte Sedimentation Rate (ESR) Indication of ongoing acute inflammation. Important since sepsis and infection are common cause of delirium. [1]
Fasting venous plasma glucose or casual venous plasma glucose Hypoglycemic and hyperglycaemic attackes can cause symptoms of delirium. [1],[2] Diabetic ketoacidosis (DKA), and Hyperosmolar non ketotic (HONK) states can also cause delirium.
Urine analysis Urine full report and culture is essential in order to rule out a urinary tract infection .[1],[3]
Liver function tests and transaminase levels; serum ammonia level. To diagnose liver failure. Inadequacy of liver function is an identified cause for confusion and delirium. [1],[4],[5]
Renal function tests: blood urea serum creatinine and electrolytes,stimated glomerular filtration rate Metabolic derrangement due to renal failure is a known cause for delirium. Delirium can be commonly seen in dialysed patients as well as in acute kidney injury. [1],[6],[7]
ECG, serum troponin and myoglobin levels, Acute hypoxic cerebral ischemia secondary to myocardial ischemia causes delirium[1],[8]
Toxicology screen (to identify drug or alcohol intoxication or withdrawal, heavy metal poisoning) These are secondary investigations after review of social history and occupational or other exposures. [1]
Thyroid function tests Endocrine abnormalities such as hypothyroidism can cause delirium, also known as myxoedema madness.[1],[9]
Serum B12 and Folate levels Vitamin B12 and Folate deficiency is associated with a wide spectrum of neuro-psychiatric manifestations including delirium.[1][10][11]
Chest X-ray Respiratory tract infection and heart disease can cause delirium. [1],[12]
Screening for STI's Usually second line investigations. HIV and VDRL can be performed. Delirium can occur in neuro-syphillis, while HIV infection can cause dementia and behavioral change. [13], [1]
Neuroimaging: CT scan, MRI May help in the diagnosis of stroke, hemorrhage and other structural cerebral lesions. [1],[14]
References
  1. MARCIA O. MILLER, Evaluation and Management of Delirium in Hospitalized Older Patients, Am Fam Physician[online]. 2008 Dec 1;78(11):1265-1270.[viewed 31 May 2014] Available from:http://www.aafp.org/afp/2008/1201/p1265.html
  2. BALHARA YP. Diabetes and psychiatric disorders Indian J Endocrinol Metab [online] 2011, 15(4):274-283 [viewed 31 May 2014] Available from: doi:10.4103/2230-8210.85579
  3. BALOGUN SA, PHILBRICK JT. Delirium, a Symptom of UTI in the Elderly: Fact or Fable? A Systematic Review Can Geriatr J [online] , 17(1):22-26 [viewed 31 May 2014] Available from: doi:10.5770/cgj.17.90
  4. FONG TG, TULEBAEV SR, INOUYE SK. Delirium in elderly adults: diagnosis, prevention and treatment Nat Rev Neurol [online] 2009 Apr, 5(4):210-220 [viewed 31 May 2014] Available from: doi:10.1038/nrneurol.2009.24
  5. LESCOT T, KARVELLAS CJ, CHAUDHURY P, TCHERVENKOV J, PARASKEVAS S, BARKUN J, METRAKOS P, GOLDBERG P, MAGDER S. Postoperative delirium in the intensive care unit predicts worse outcomes in liver transplant recipients Can J Gastroenterol [online] 2013 Apr, 27(4):207-212 [viewed 31 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3742477
  6. DE SOUSA A. Psychiatric issues in renal failure and dialysis Indian J Nephrol [online] 2008 Apr, 18(2):47-50 [viewed 31 May 2014] Available from: doi:10.4103/0971-4065.42337
  7. MURRAY AM. Cognitive Impairment in the Aging Dialysis and Chronic Kidney Disease Populations: an Occult Burden Adv Chronic Kidney Dis [online] 2008 Apr, 15(2):123-132 [viewed 31 May 2014] Available from: doi:10.1053/j.ackd.2008.01.010
  8. YOGARATNAM J, JACOB R, NAIK S, MAGADI H, SIM K. Prolonged Delirium Secondary to Hypoxic-ischemic Encephalopathy Following Cardiac Arrest Clin Psychopharmacol Neurosci [online] 2013 Apr, 11(1):39-42 [viewed 31 May 2014] Available from: doi:10.9758/cpn.2013.11.1.39
  9. HEINRICH TW, GRAHM G. Hypothyroidism Presenting as Psychosis: Myxedema Madness Revisited Prim Care Companion J Clin Psychiatry [online] 2003, 5(6):260-266 [viewed 31 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419396
  10. OSIEZAGHA K, ALI S, FREEMAN C, BARKER NC, JABEEN S, MAITRA S, OLAGBEMIRO Y, RICHIE W, BAILEY RK. Thiamine Deficiency and Delirium Innov Clin Neurosci [online] , 10(4):26-32 [viewed 31 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3659035
  11. KIBIRIGE D, WEKESA C, KADDU-MUKASA M, WAISWA M. Vitamin B12 deficiency presenting as an acute confusional state: a case report and review of literature Afr Health Sci [online] 2013 Sep, 13(3):850-852 [viewed 31 May 2014] Available from: doi:10.4314/ahs.v13i3.47
  12. BAIL K, BERRY H, GREALISH L, DRAPER B, KARMEL R, GIBSON D, PEUT A. Potentially preventable complications of urinary tract infections, pressure areas, pneumonia, and delirium in hospitalised dementia patients: retrospective cohort study BMJ Open [online] , 3(6):e002770 [viewed 31 May 2014] Available from: doi:10.1136/bmjopen-2013-002770
  13. SCOTT KR, BARRETT AM. Dementia syndromes: evaluation and treatment Expert Rev Neurother [online] 2007 Apr, 7(4):407-422 [viewed 31 May 2014] Available from: doi:10.1586/14737175.7.4.407
  14. FONG TG, TULEBAEV SR, INOUYE SK. Delirium in elderly adults: diagnosis, prevention and treatment Nat Rev Neurol [online] 2009 Apr, 5(4):210-220 [viewed 31 May 2014] Available from: doi:10.1038/nrneurol.2009.24
  15. NOUYE SK, FERRUCCI L. Elucidating the Pathophysiology of Delirium and the Interrelationship of Delirium and Dementia J Gerontol A Biol Sci Med Sci [online] 2006 Dec, 61(12):1277-1280 [viewed 31 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2645654

Management - General Measures

Fact Explanation
Education of patient and family Education involves patient, family and hospital staff. Staff should be informed of the restless nature of the patient and also that this is not a psychiatric illness.
Provision of support and orientation Patients are disoriented and restless. During communication medical staff should avoid medical jargon. Simple and clear instruction should be given. There should be signs displaying time,date and place to re-orient the patient. Caregivers and staff should be consistent to avoid confusion.Family members and caregivers must encourage feelings of security and orientation[1],[2]
Maintain a safe environment Patients should be managed in a safe environment to minimize harm. A bar bed minimizes the risk of falling, the bedside table should be cleared of glass bottles, medical equipment and drugs that can cause harm.[2] One to one supervision may be needed in cases of agitation. [1],[2]
General supportive measures This includes correcting dehydration, ensuring adequate nutrition, providing bladder, bowel and skin care, and ensuring good general hygiene.
References
  1. ONDRIA C. GLEASON,Delirium,Am Fam Physician[online]. 2003 Mar 1;67(5):1027-1034.[viewed 29 May 2014] Available from:http://www.aafp.org/afp/2003/0301/p1027.html
  2. MARCIA O. MILLER, Evaluation and Management of Delirium in Hospitalized Older Patients, Am Fam Physician[online]. 2008 Dec 1;78(11):1265-1270.[viewed 31 May 2014] Available from:http://www.aafp.org/afp/2008/1201/p1265.html
  3. FONG TG, TULEBAEV SR, INOUYE SK. Delirium in elderly adults: diagnosis, prevention and treatment Nat Rev Neurol [online] 2009 Apr, 5(4):210-220 [viewed 31 May 2014] Available from: doi:10.1038/nrneurol.2009.24
  4. TAKEUCHI A, AHERN TL, HENDERSON SO. Excited Delirium West J Emerg Med [online] 2011 Feb, 12(1):77-83 [viewed 31 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088378

Management - Specific Treatments

Fact Explanation
Treatment of underlying aetiology Specific management of delirium consists of identification and prompt treatment of the offending etiology. [1]
Typical anti psychotics The most widely used anti psychotic is Haloperidol. This is effective in reducing agitation, hallucinations and delusions. Treatment should be initiated with small doses of, 0.5 to 1 mg orally in twice daily regimen. Additional doses can be added based on the response.
Atypical anti psychotics Risperidone, Olanzapine and Quetapine are also used and they have reduced extra pyramidal side effects. Recent studies have shown that low dose Quetiapine is equally effective and safe for controlling delirium symptoms, as Haloperidol.[1][2]
Benzodiazepines Benzodiazepines are recommended in the treatment of delirium due to alcohol withdrawal. Studies have revealed that the use of benzodiazepines in intensive care is associated with a longer duration of the first episode of delirium. [4],[1]
References
  1. MARCIA O. MILLER,Evaluation and Management of Delirium in Hospitalized Older Patients, Am Fam Physician[online]. 2008 Dec 1;78(11):1265-1270.[viewed 31 May 2014] Available from:http://www.aafp.org/afp/2008/1201/p1265.html
  2. MANEETON B, MANEETON N, SRISURAPANONT M, CHITTAWATANARAT K. Quetiapine versus haloperidol in the treatment of delirium: a double-blind, randomized, controlled trial Drug Des Devel Ther [online] :657-667 [viewed 31 May 2014] Available from: doi:10.2147/DDDT.S45575
  3. ROBINSON TN, EISEMAN B. Postoperative delirium in the elderly: diagnosis and management Clin Interv Aging [online] 2008 Jun, 3(2):351-355 [viewed 31 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546478
  4. PISANI MA, MURPHY TE, ARAUJO KL, SLATTUM P, VAN NESS PH, INOUYE SK. Benzodiazepine and opioid use and the duration of ICU delirium in an older population Crit Care Med [online] 2009 Jan, 37(1):177-183 [viewed 31 May 2014] Available from: doi:10.1097/CCM.0b013e318192fcf9