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Delirium

For further information, see CMDT Part 25-20: Neurocognitive Disorders

For further information, see CMDT Part 24-14: Dementia

Key Features

Essentials of Diagnosis

  • Acute confusional state

  • Transient global disorder of attention, with clouding of consciousness

  • Usually a result of systemic problems (eg, drugs, hypoxemia)

General Considerations

  • The organic problem may be a primary brain disorder or a secondary manifestation of some general disorder

  • The causes of cognitive disorders are listed in Table 25–11

  • Should be considered a syndrome of acute brain dysfunction analogous to acute kidney injury

  • Terminal delirium occurs commonly at the end of life

    • May be related to multiple medical causes, including organ failure

    • May be unrecognized

Table 25–11.Etiology of delirium and other cognitive disorders.
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Table 25–11. Etiology of delirium and other cognitive disorders.
Disorder Possible Causes
Intoxication Alcohol, sedatives, bromides, analgesics (eg, pentazocine), psychedelic drugs, stimulants, and household solvents.
Medication withdrawal Withdrawal from alcohol, sedative-hypnotics, corticosteroids.
Long-term effects of alcohol Wernicke-Korsakoff syndrome.
Infections Septicemia; meningitis and encephalitis due to bacterial, viral, fungal, parasitic, or tuberculous organisms or to central nervous system syphilis; acute and chronic infections due to the entire range of microbiologic pathogens.
Endocrine disorders Thyrotoxicosis, hypothyroidism, adrenocortical dysfunction (including Addison disease and Cushing syndrome), pheochromocytoma, insulinoma, hypoglycemia, hyperparathyroidism, hypoparathyroidism, panhypopituitarism, diabetic ketoacidosis.
Respiratory disorders Hypoxia, hypercapnia.
Metabolic disturbances Fluid and electrolyte disturbances (especially hyponatremia, hypomagnesemia, and hypercalcemia), acid-base disorders, hepatic disease (hepatic encephalopathy), kidney failure, porphyria.
Nutritional deficiencies Deficiency of vitamin B1 (beriberi), vitamin B12 (pernicious anemia), folic acid, nicotinic acid (pellagra); protein-calorie malnutrition.
Trauma Subdural hematoma, subarachnoid hemorrhage, intracerebral bleeding, concussion syndrome.
Cardiovascular disorders Myocardial infarctions, cardiac arrhythmias, cerebrovascular spasms, hypertensive encephalopathy, hemorrhages, embolisms, and occlusions indirectly cause decreased cognitive function.
Neoplasms Primary or metastatic lesions of the central nervous system, cancer-induced hypercalcemia.
Seizure disorders Ictal, interictal, and postictal dysfunction.
Collagen-vascular and immunologic disorders Autoimmune disorders, including systemic lupus erythematosus, Sjögren syndrome, and AIDS.
Degenerative diseases Alzheimer disease, Pick disease, multiple sclerosis, parkinsonism, Huntington chorea, normal pressure hydrocephalus.
Medications Anticholinergic medications, antidepressants, H2-blocking agents, digoxin, salicylates (long-term use), and a wide variety of other over-the-counter and prescribed medications.

Demographics

  • Alcohol or substance withdrawal is the most common cause of delirium in the general hospital

Clinical Findings

Symptoms and Signs

  • Onset is usually rapid

  • The mental status fluctuates (impairment is usually least in the morning), with varying inability to concentrate, maintain attention, and sustain purposeful behavior

  • “Sundowning"—mild to moderate delirium at night

    • More common in patients with preexisting dementia

    • May be precipitated by hospitalization, drugs, and sensory deprivation

  • There is a marked deficit of memory and recall

  • Anxiety and irritability are common

  • Orientation problems follow the inability to retain information

  • Perceptual ...

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