Delirium

Delirium (Also known as Acute Confusional State, Acute Brain Syndrome, Acute Brain Failure)

Key Points to Know:

• Delirium is considered an emergency condition.

• Key characteristics include:

• Acute/short-term changes in cognitive function, often affecting attention (patients may not maintain eye contact), disorientation (usually in the order of time first, then place, and person last, though this can reverse), and other cognitive functions.

• Clouded consciousness where the patient is not fully aware but is not unresponsive.

• Symptoms fluctuate, often worsening at night with symptomatic and lucid intervals during which symptoms may disappear.

• Possible psychotic symptoms.

• Insomnia, abnormal sleep-wake cycle, anterograde amnesia.

• There are three subtypes: hyperactive (most common), hypoactive, and mixed.

• It is important to differentiate from delirium tremens associated with alcohol withdrawal syndrome as the treatments differ, especially in cases of hyperactive delirium.

Causes are categorized into two main groups:

• Extracranial Causes:

• Fever/infection (especially UTIs)

• Dehydration, urinary retention, constipation

• Anemia, malnutrition

• Pain, trauma, major operations

• Metabolic issues like electrolyte imbalances

• Endocrine disorders such as hyper/hypoglycemia, thyroid diseases

• Cardiovascular/pulmonary disease

• Medications including sedatives, hypnotics, anticholinergic drugs, antipsychotic drugs

• Hypoxia: brain hypoxia, post-arrest scenarios

• Intracranial Causes:

• Meningitis/encephalitis, hypertensive encephalopathy, CVA, subdural hematoma, postictal states

Management:

• Identify and Treat Causes/Precipitating Factors: Work-up specific causes as identified, e.g., septic work-up, blood chemistry based on suspected cause.

• Supportive Treatments: Address insomnia and manage psychotic symptoms.

• Medication Order: Prefer high potency 1st generation antipsychotic drugs like haloperidol and 2nd generation antipsychotic drugs such as risperidone, clozapine, olanzapine, quetiapine, aripiprazole due to their lower anticholinergic effect. Antipsychotic drugs can reduce impulsive symptoms and aggression in hyperactive delirium as well as in the hypoactive subtype.

Supportive Environment (Highly Ideal):

• Enhance orientation to time, place, and person for the patient to improve awareness.

• Time: Use visible clocks, brighten lights during the day, open curtains in the morning, and ensure night lights are on during the night.

• Place: Use familiar items from the patient's home environment, place them nearby.

• Person: Encourage family visits, have consistent medical personnel interact with the patient daily.

• Address sensory deficits, such as hearing and vision impairments.

• Use restraints judiciously in cases of significant agitation.