Delirium

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Lecture outline :

1. Introduction
2. Epidemiology & Predisposing factor
3. Etiology
4. Neuropathology of Delirium
5. Clinical Features & Diagnostic criteria for Delirium
6. Course & Outcome
7. Mini mental examination
8. Physical Examination & Lab. Investigations
9. Treatment
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Delirium is defined by the acute onset of fluctuating cognitive
impairment and a disturbance of consciousness. It is a
medical emergency.

The etiologies of delirium are , multifactorial & often reflect

the pathophysiologic consequences of an acute medical
illness , medical complications, drug intoxication, or drug
withdrawal

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Delirium by Other Names :
Intensive care unit psychosis, Acute confusional state,
Acute brain failure, Encephalitis, Encephalopathy, Toxic
metabolic state

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 Epidemiology

Overall prevalence in the community(1-2%)

Common disorder in elderly patients
medically ill elderly patients at emergency (10-30%)
Hospitalized patients (14-24%) , rising to (6-56) during their
stay in hospital
Postoperative elderly patients (15-53%)
For patients in ICU (70-87%)
Near-death terminal patients up to(83%)

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Predisposing factor

1. Old age (age 60 years or over)

2. AIDS
3. Pre-exsisting brain damage (dementia, cardiovascular
disease, tumor)
4. History of alcohol dependence, diabetes, cancer,
malnutrition

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Etiology

I. Intracranial causes

II. Extracranial causes

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I. Intracranial causes

Epilepsy & Postictal State

Brain Trauma (Especially Concussion)
Infections (Meningitis, Encephalitis)
Neoplasms
Vascular Disorders

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II. Extracranial causes

A. Medications &Substances (ingestion or withdrawal)

e.g., Digitals, steroids, insulin, anticholinergic agents ,
sedatives (including alcohol) & hypnotics
B. Poisons e.g., Carbon monoxide, Heavy metals & other
industrial poisons
C. Endocrine dysfunction
e.g., Thyroid, Parathyroid, Pancreas, Adrenal

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C. Endocrine dysfunction
e.g., Thyroid, Parathyroid, Pancreas, Adrenal

D. Disease of none-endocrine organs

e.g., Liver (hepatic encephalopathy)
Kidney & urinary tract (Uremic encephalopathy)
Cardiovascular system (cardiac failure,
arrhythmias, hypotension)
Lung ( hypoxia, carbon dioxide necrosis)

E. Deficiency disorders
e.g., Thiamine, nicotinic acid, B12, folic acid
deficiencies 10
Others

Systemic infections with fever & sepsis

Electrolyte imbalance of any cause
Postoperative state
Trauma (head or general body)
Sleep deprivation, Sensory deprivation & sensory over load

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Neuropathology of Delirium

Not fully understood

 Delirium is associated with the dysfunction of the reticular
formation of the brainstem (regulating arousal &
attention)
 Delirium is common with increased dopamine & decreased
acetylcholine activity in the brain.
 Other pathophysiology of delirium is hyperactivity of the
locus cerulus & its neuroadrnergic neurons (e.g., alcohol
withdrawal delirium or Delirium Tremens)

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 Clinical Features

Common clinical features of delirium:

1.Emotional disturbances
2.Psychomotor disturbances
3.Disturbance in consciousness & attention
4.Disorientation
5.Impaired memory
6.Perceptual disturbances
7.Thought disturbances
8.sleep-wake cycle disruption
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1.Emotional disturbances

Patient may exhibit anxiety, Irritability, depressed mood, even

euphoria

2.Psychomotor disturbances

Patient with delirium may be in sate of :

A. Hypoactive
B. Hyperactive
C. Mixed

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A. Hypoactive
Extreme fatigue & slow to respond
Increased sleep

B. Hyperactive
May become agitated & violent
Remove IV lines, dressing & catheters
Restless & try to get out of bed
sleepless

C. Mixed
Mixture of agitation & hypoactive behaviors that can vary
through out the day 15
3. Disturbances in consciousness & attention
reduced clarity of awareness of the environment
inability to focus, sustain or shift attention

4. Disorientation
Usually disoriented to time, to place, rarely to person

5. Impaired memory
Failure to register events into memory
patients fail test of memory (almost all types of memory)

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6. Perceptual Disturbances
Illusions, Or Hallucinations

7. Thought disturbances
Disorganization of thought process (rambling /
incoherent speech)
Delusions (e.g., persecutory delusion)

8. Sleep-wake cycle disruption

Fragmented sleep at night, with or without daytime
drowsiness

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DSM5-Diagnostic Criteria for Delirium
A. A disturbance in attention & awareness
B The disturbance develops over a short period of time, &
tends to fluctuate in severity during the course of a day
C. An additional disturbance in cognition ( memory deficit,
disorientation, language, visuo-spatial ability, or
perception)
D. Criteria A & C are not better explained by another
preexisting, established, or evolving Neurocognitive
disorder (NCD) & do not occur in the context of a severely
reduced level of arousal (coma)
E. There is evidence from the Hx , PE / Lab findings that the
disturbance is a direct physiological consequence of
another medical condition, substance intoxication or
withdrawal , or exposure to a toxin, or is due to multiple
etiologies. 18
Mini-Mental State Examination(MMSE)

 It is a screening test & used during a patient's clinical

examination.
 It is a practical test to track the changes in a patient’s
cognitive state.
 Of a possible 30 points, a score below 25 suggests possible
impairment,& a score below 20 indicates definite
impairment.

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MMSE :
Orientation (score 1 if correct)
Name this hospital, or building? ___ What state are you in? ___
What city are you in now? ___ What country is it? ___
What year is it? ___ What floor of the building are you on? ___
What month is it? ___ What day of the week is it? ___
What is the date today? ___ What season of the year is it? ___
Registration (score 1 for each object correctly repeated)
Name three objects ___
Attention & calculation (sc.=5) Subtraction 7 from 100 in serial fashion to 65 ___
Recall (score 1 for each object recalled) ___
Do you recall the three objects named before? ___
Language tests
Confrontation naming: watch, pen=2 ___
Repetition ”No ifs, ands, or buts”=1 ___
Comprehension: Pick up the paper in your right hand, fold it in half, set in the
floor=3 ___
Read & perform the command “close your eyes”=1 ___
Write any sentence =1. ___
Construction: copy the design (pentagon ) =1 ___
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Evaluation of patient with suspected delirium

• Assess the patient’s consciousness, behavior & level of

cooperativeness
• Look at the overall time course
• Review medication list including ,doses, recent medications
( discontinued / started)
• Evaluate for recent medical illness & interventions
• Screen for history of substance use disorder (withdrawal /
intoxication )
• Review diagnostic studies including labs, imaging
• Gather collateral information from family/friends regarding
medical, psychiastric history
• Physical exam including neurologic exam, MMSE, vital signs
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Work up
 Arterial blood gas or Oxygen
•CBC
saturation
•OFT
 Urinalysis +/- Culture and
•Electrolytes sensitivity
•EKG  Urine drug screen
•CXR  Blood alcohol
•EEG  Serum drug levels (digoxin,
•CT,MRI theophylline, phenobarbital,
lithium, etc)

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Specify whether (Etiological factor)

Substance intoxication delirium

Substance withdrawal delirium
Medication-induced delirium
Delirium due to another medical condition
Delirium due to multiple etiologies

Specify if (psychomotor activity)

Hyperactive
Hypoactive
mixed
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Course

• Acute: Lasting a few hours or days

• Persistent: Lasting weeks or months

 usually persist as long as the casual relevant factors are

present & generally lasts less than a week
 may have unpredictable fluctuations in severity

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Prognosis

 Full recovery
 Progression to stupor & or coma
 Progression to chronic brain syndromes (e.g., Amnestic
syndromes)
 Development of seizure (e.g., Alcohol withdrawal)
 Death

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 Differential Diagnosis

1. Brief psychotic disorder, schizophrenia, mood

disorders with psychotic features.
 In delirium the psychotic symptoms fluctuate, & occur in
altered level of consciousness. Impaired attention memory
& disorientation

2. Substance intoxication or withdrawal

 The diagnosis of delirium can be made only the symptoms
of the delirium are in excess of those usually associated
with the intoxication or withdrawal syndrome

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 3. Dementia

 Insidious onset
 Symptoms usually do not fluctuate over the course of a day
 No change on level of consciousness (patient is alert)

4. Depression

• Absence of altered consciousness

• The presence of prominent depressive symptoms

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Treatment

1.Identify & treat the underlying cause

2.Environmental & psychosocial interventions
3.Psychopharmacological treatment

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1. Identify & treat the underlying cause
History taking
Physical Examination
Lab investigations
Appropriate & immediate treatment of the
medical condition

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2. Environmental & psychosocial interventions

 keeping noise levels to a minimum

 lower the light intensity at interval
 scheduling procedures as much as possible at day time so as to
avoid waking the patient at night
 reorient patient as often as possible ( to time , place & person)
 protect the patient from unwanted self-harm
 friend or relative should be stay at all times with the patient

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3. Psychopharmacological treatment

Treat psychosis & insomnia

Haloperidol
Lorazepam

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 Erasinus, who lived near the Canal of Bootes, was
seized with fever after supper; passed the night in an
agitated state. During the first day quiet, but in pain at
night. On the second, symptoms all exacerbated; at night
delirious. On the third, was in a painful condition; great
incoherence. On the fourth, in a most uncomfortable state;
had no sound sleep at night, but dreaming and talking;
then all the appearances worse, of a formidable and
alarming character; fear, impatience. On the morning of
the fifth, was composed, and quite coherent, but long
before noon was furiously mad, so that he could not
constrain himself; extremities cold, and somewhat livid;
urine without sediment; died about sunset.
Hipocratus (400 BC)
THANK YOU !

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