Chapter 25

Confusion, a mental and behavioral state of reduced comprehension, coherence, and capacity to reason, is one of the most common problems encountered in medicine, accounting for a large number of emergency department visits, hospital admissions, and inpatient consultations. Delirium, a term used to describe an acute confusional state, remains a major cause of morbidity and mortality rates, costing billions of dollars yearly in health care costs in the United States alone. Delirium often goes unrecognized despite clear evidence that it is usually the cognitive manifestation of serious underlying medical or neurologic illness.

### Clinical Features of Delirium

A multitude of terms are used to describe delirium, including encephalopathy, acute brain failure, acute confusional state, and postoperative or intensive care unit (ICU) psychosis. Delirium has many clinical manifestations, but essentially it is defined as a relatively acute decline in cognition that fluctuates over hours or days. The hallmark of delirium is a deficit of attention, although all cognitive domains—including memory, executive function, visuospatial tasks, and language—are variably involved. Associated symptoms may include altered sleep-wake cycles, perceptual disturbances such as hallucinations or delusions, affect changes, and autonomic findings that include heart rate and blood pressure instability.

Delirium is a clinical diagnosis that can be made only at the bedside. Two broad clinical categories have been described—the hyperactive and hypoactive subtypes—that are based on differential psychomotor features. The cognitive syndrome associated with severe alcohol withdrawal remains the classic example of the hyperactive subtype, featuring prominent hallucinations, agitation, and hyperarousal, often accompanied by life-threatening autonomic instability. In striking contrast is the hypoactive subtype, exemplified by opiate intoxication, in which patients are withdrawn and quiet, with prominent apathy and psychomotor slowing.

This dichotomy between subtypes of delirium is a useful construct, but patients often fall somewhere along a spectrum between the hyperactive and hypoactive extremes, sometimes fluctuating from one to the other within minutes. Therefore, clinicians must recognize the broad range of presentations of delirium to identify all patients with this potentially reversible cognitive disturbance. Hyperactive patients, such as those with delirium tremens, are easily recognized by their characteristic severe agitation, tremor, hallucinations, and autonomic instability. Patients who are quietly disturbed are overlooked more often on the medical wards and in the ICU, yet multiple studies suggest that this underrecognized hypoactive subtype is associated with worse outcomes.

The reversibility of delirium is emphasized because many etiologies, such as systemic infection and medication effects, can be treated easily. However, the long-term cognitive effects of delirium remain largely unknown and understudied. Some episodes of delirium continue for weeks, months, or even years. The persistence of delirium in some patients and its high recurrence rate may be due to inadequate treatment of the underlying etiology of the syndrome. In some instances, delirium does not disappear because there is underlying permanent neuronal damage. Even after an episode of delirium resolves, there may be lingering effects of the disorder. ...

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