Delirium

Central nervous system

Alternative names

Acute confusional state; Acute brain syndrome

Definition 

A condition of severe confusion and rapid changes in brain function, usually the result of treatable physical or mental illness.

Causes and risks

Acute confusional states are usually the result of a physical or mental illness and are usually temporary and reversible.

Delirium involves a rapid alternation between mental states (for example, from lethargy to agitation and back to lethargy), with attention disruption, disorganized thinking, disorientation, changes in sensation and perception, and other symptoms.

Disorders that cause delirium are numerous and varied. They may include conditions that deprive the brain of oxygen or other substances. Delirium may be caused by diseases of body systems other than the brain, by poisons, by fluid/electrolyte or acid/base disturbances, and by other serious, acute conditions.

Prevention

Treatment of causative disorders and conditions reduces the risk of delirium.

Symptoms

• attention disturbance (disrupted or wandering attention)
  • inability to maintain goal directed, purposeful thinking or behavior
  • inability to concentrate
• disorganized thinking, evidenced by
  • incoherent speech
  • inability to stop speech patterns or behaviors
• disorientation to time or place
• changes in sensation and perception (increases the disorientation)
  • may precipitate illusions or hallucinations
• altered level of consciousness or awareness
• altered sleep patterns, drowsiness
• alertness may vary, usually more alert in the morning, less alert at night (see drowsiness)
• decrease in short-term memory and recall
  • unable to recall events since onset of delirium (anterograde amnesia)
  • unable to recall past events (retrograde amnesia)
• changes in motor activities, movement (for example, may be lethargic or slow moving)
• ovements triggered by changes in the nervous system (psychomotor restlessness)
• emotional or personality changes
  • anxiety
  • anger
  • apathy
  • depression
  • euphoria
  • irritability

Signs and tests

Neurologic examination may reveal abnormalities, including abnormal reflexes and abnormal levels of normal reflexes. Psychologic studies and tests of sensation, cognitive function, and motor function may be abnormal.

The specific lesion, extent of damage, and cause of delirium may be indicated by the results of tests and procedures, including, but not limited to:

• serum electrolytes
• blood chemistry (chem-20)
• serum calcium
• glucose test
• serum magnesium - test
• CPK
• liver function tests
• ammonia levels
• thyroid stimulating hormone level
• thyroid function tests
• B-12 level
• drug, alcohol levels (toxicology screen)
• urinalysis
• blood gas analysis
• EEG, electroencephalograph
• head CT scan
• head MRI scan
• CSF (cerebrospinal fluid) analysis
• chest x-ray

Treatment

The goal of treatment is to control or reverse symptoms. Treatment varies with the specific condition causing delirium. The person should be in a pleasant, comfortable, non-threatening, physically safe environment for diagnosis and initial treatment. Hospitalization may be required for a short time.

The cause should be identified and treated.

Stopping or changing medications that worsen confusion, or that are not essential to the care of the person, may improve cognitive functioning even before treatment of the underlying disorder. Medications that may worsen confusion include anticholinergics, analgesics, cimetidine, central nervous system depressants, lidocaine, and other medications.

Disorders that contribute to confusion should be treated. These may include heart failure, decreased oxygen (hypoxia), excessive carbon dioxide levels (hypercapnia), thyroid disorders, anemia, nutritional disorders, infections, kidney failure, liver failure, and psychiatric conditions such as depression. Correction of co-existing medical and psychiatric disorders often greatly improve mental functioning.

Medications may be required to control aggressive or agitated behaviors or behaviors that are dangerous to the person or to others. These are usually given in very low doses, with adjustment as required.

Medications that may be considered for use include:

• thiamine
• sedating medications such as clonazepam or diazepam
• serotonin-affecting drugs (trazodone, buspirone)
• dopamine blockers (such as haloperidol, olanzapine, risperidol, clozapine)
• fluoxetine, imipramine, celexa (may help stabilize mood)

Sensory functioning should be evaluated and augmented as needed by the use of hearing aids, glasses or cataract surgery.

Formal psychiatric treatment may be necessary. Behavior modification may be helpful for some people to control unacceptable or dangerous behaviors. This consists of rewarding appropriate or positive behaviors and ignoring inappropriate behaviors (within the bounds of safety). Reality orientation, with repeated reinforcement of environmental and other cues, may help reduce disorientation.

Prognosis

The outcome varies. Acute disorders that cause delirium may co-exist with chronic disorders that cause dementia. Acute brain syndromes may be reversible with treatment of the underlying cause. Delirium often lasts only about 1 week, although it may take several weeks for cognitive function to return to normal levels. Full recovery is common.