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Chapter 79. Delirium

Karin J. Neufeld, MD, MPH; Amy Huberman, MD; Dale M. Needham, MD, PhD

  1. What is the prevalence of delirium in hospitalized patient populations?

  2. What are the most common causes of delirium?

  3. Why is it important to detect delirium?

  4. What are the symptoms of delirium?

  5. How is delirium diagnosed?

  6. How can delirium be prevented and treated?

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Case 79-1

A 56-year-old bank manager with a history of lumbar stenosis and major depression was admitted to the hospital five days ago with cellulitis of the left thigh. He was started empirically on intravenous cefazolin, and his fever (40° Celsius on admission) resolved over 96 hours. During his hospital stay, he was given his home dose of fluoxetine 30 mg daily. During preparation of discharge paperwork the medical team is informed that he is pulling at his intravenous line and threatening to leave against medical advice. Excitedly reaching into the air in front of him, he comments “I'm popping the bubbles.” When no bubbles are observed, what should be the next steps?

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Case 79-2

A 73-year-old retired secretary with a history of hypertension, diabetes, and hypercholesterolemia, was readmitted from an acute rehabilitation facility for failure to thrive. She was discharged from the hospital one week ago, after having recovered uneventfully from a thoracoabdominal aortic aneurysm repair two weeks earlier. Her nurse at the rehabilitation facility informed the medical team that “she was just not motivated to get better—she refused physical therapy and would not eat her meals.” Her daughter reports that “before her surgery she had all her marbles, but now she gets confused about where she is, and sometimes she doesn't even recognize me.” During family visits she was unusually distractible and drowsy during the day. How should the health care team approach this problem?

Delirium is common in hospitalized patients. The prevalence of delirium may be as high as 80% in mechanically ventilated patients in the intensive care unit (ICU), 50% in geriatric postoperative patients, and 10% to 40% in general medical patients. Patients who develop delirium frequently have multiple risk factors. These include nonmodifiable factors, such as increased age, preexisting cognitive impairment, and a history of prior stroke or brain injury. Important modifiable risk factors include (1) exposure to deliriogenic medications, (2) infection, (3) metabolic derangement, (4) organ failure, (5) dehydration, (6) malnutrition, (7) surgery, (8) immobility, (9) use of physical restraints, (10) sensory impairment, (11) sleep deprivation, (12) pain, and (13) drug withdrawal or intoxication.

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Practice Point

Delirium as a red flag

  • Think of delirium as a nonspecific warning sign, like fever or hypotension, that something serious may be wrong and requires further investigation. Thirty-nine percent of inpatients with delirium die within one year. Don't ignore this red flag.

Delirium is associated with increased mortality, morbidity, and length of stay. Estimates of annual U.S. health care costs attributed to delirium ...

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