Sections

Delirium

Sections Delirium
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Guidelines
Medication
Follow-up
Questions & Answers
Tables
References

Guidelines

Guidelines Summary

Scottish Intercollegiate Guidelines Network

Guidelines for risk reduction and management of delirium were published by the Scottish Intercollegiate Guidelines Network (SIGN) in March 2019.^[74]

Detecting delirium

Use the 4 As Test (Arousal, Attention, Abbreviated Mental Test 4 [AMT4], Acute change) for identifying patients with probable delirium in emergency and acute hospital settings. This tool may also be used in community or other settings.

In the ICU setting, use the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) to identify patients with probable delirium.

Use CT brain scan in those patients presenting with delirium in the presence of the following:

New focal neurological signs
Reduced level of consciousness
A history of falls
Head injury
Anticoagulation therapy

Consider an electroencephalogram when there is suspicion of epileptic activity or non-convulsive status epilepticus.

Reducing risk of delirium

Consider all of the following as part of a package of care for patients at risk for delirium:

Ensuring patients have their glasses and hearing aids, if applicable
Promoting sleep hygiene
Early mobilization
Pain control
Prevention, early identification, and treatment of post-operative complications
Maintaining optimal hydration and nutrition
Regulation of bladder and bowel function
Provisions of supplementary oxygen, if appropriate

Monitor depth of anesthesia in patients 60 years of age and over undergoing surgery that is expected to last more than 1 hr.

Treating delirium

Consider acute, life-threatening causes of delirium. These may include low oxygen level, low blood pressure, low glucose level, and drug intoxication or withdrawal.

Identify and treat potential causes such as medications and acute illness. Multiple causes are common.

Optimize physiology, environment, and medications to promote brain recovery.

Detect and treat agitation or distress with non-pharmacologic means, if possible.

Communicate diagnosis to patients and caregivers and provide ongoing support.

Attempt to prevent delirium complications such as immobility, falls, pressure sores, dehydration, malnourishment, and isolation.

Monitor patient recovery and refer to a specialist if necessary.

Medication

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th ed. Washington, DC: American Psychiatric Association; 2013.
Kalabalik J, Brunetti L, El-Srougy R. Intensive care unit delirium: a review of the literature. J Pharm Pract. 2014 Apr. 27 (2):195-207. [QxMD MEDLINE Link].
Maldonado JR. Neuropathogenesis of delirium: review of current etiologic theories and common pathways. Am J Geriatr Psychiatry. 2013 Dec. 21 (12):1190-222. [QxMD MEDLINE Link].
White S. The neuropathogenesis of delirium. Rev Clin Gerontol. 2002. 12:62-67.
Cerejeira J, Batista P, Nogueira V, et al. Low preoperative plasma cholinesterase activity as a risk marker of postoperative delirium in elderly patients. Age Ageing. 2011 Sep. 40(5):621-6. [QxMD MEDLINE Link].
Robinson TN, Eiseman B. Postoperative delirium in the elderly: diagnosis and management. Clin Interv Aging. 2008. 3 (2):351-5. [QxMD MEDLINE Link].
Shigeta H, Yasui A, Nimura Y, et al. Postoperative delirium and melatonin levels in elderly patients. Am J Surg. 2001 Nov. 182(5):449-54. [QxMD MEDLINE Link].
de Rooij SE, van Munster BC, Korevaar JC, Levi M. Cytokines and acute phase response in delirium. J Psychosom Res. 2007 May. 62(5):521-5. [QxMD MEDLINE Link].
Rudolph JL, Ramlawi B, Kuchel GA, et al. Chemokines are associated with delirium after cardiac surgery. J Gerontol A Biol Sci Med Sci. 2008 Feb. 63(2):184-9. [QxMD MEDLINE Link]. [Full Text].
Ebersoldt M, Sharshar T, Annane D. Sepsis-associated delirium. Intensive Care Med. 2007 Jun. 33(6):941-50. [QxMD MEDLINE Link].
Banks WH. The aged blood- brain barrier: A substrate for CNS disease. Facts, Research and Intervention in Geriatrics. 2000. 2000(2):521-530.
Brown LJ, McGrory S, McLaren L, Starr JM, Deary IJ, Maclullich AM. Cognitive visual perceptual deficits in patients with delirium. J Neurol Neurosurg Psychiatry. 2009 Jun. 80(6):594-9. [QxMD MEDLINE Link].
Limosin F, Loze JY, Boni C, et al. The A9 allele of the dopamine transporter gene increases the risk of visual hallucinations during alcohol withdrawal in alcohol-dependent women. Neurosci Lett. 2004 May 20. 362(2):91-4. [QxMD MEDLINE Link].
McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium predicts 12-month mortality. Arch Intern Med. 2002 Feb 25. 162(4):457-63. [QxMD MEDLINE Link].
American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry. 1999 May. 156(5 Suppl):1-20. [QxMD MEDLINE Link].
Salluh JI, Wang H, Schneider EB, Nagaraja N, Yenokyan G, Damluji A, et al. Outcome of delirium in critically ill patients: systematic review and meta-analysis. BMJ. 2015 Jun 3. 350:h2538. [QxMD MEDLINE Link].
Marcantonio ER, Kiely DK, Simon SE, et al. Outcomes of older people admitted to postacute facilities with delirium. J Am Geriatr Soc. 2005 Jun. 53(6):963-9. [QxMD MEDLINE Link].
Pauley E, Lishmanov A, Schumann S, Gala GJ, van Diepen S, Katz JN. Delirium is a robust predictor of morbidity and mortality among critically ill patients treated in the cardiac intensive care unit. Am Heart J. 2015 Jul. 170 (1):79-86, 86.e1. [QxMD MEDLINE Link].
Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing. 2006 Jul. 35 (4):350-64. [QxMD MEDLINE Link].
Folstein MF, Folstein SE, McGugh PR. "Mini- Mental State".A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. Nov. 1975. 12(3):189-98.
Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. Apr 1983. 17:37-49.
McAvay GJ, Van Ness PH, Bogardus ST Jr, Zhang Y, Leslie DL, Leo-Summers LS. Depressive symptoms and the risk of incident delirium in older hospitalized adults. J Am Geriatr Soc. 2007 May. 55(5):684-91. [QxMD MEDLINE Link].
Farrell KR, Ganzini L. Misdiagnosing delirium as depression in medically ill elderly patients. Arch Intern Med. 1995 Dec 11-25. 155(22):2459-64. [QxMD MEDLINE Link].
Cole M, McCusker J, Dendukuri N, Han L. The prognostic significance of subsyndromal delirium in elderly medical inpatients. J Am Geriatr Soc. 2003 Jun. 51(6):754-60. [QxMD MEDLINE Link].
Ouimet S, Riker R, Bergeron N, Cossette M, Kavanagh B, Skrobik Y. Subsyndromal delirium in the ICU: evidence for a disease spectrum. Intensive Care Med. 2007 Jun. 33(6):1007-13. [QxMD MEDLINE Link].
Inouye SK, van Dyck CH, Alessi CA. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990 Dec 15. 113(12):941-8. [QxMD MEDLINE Link].
Alagiakrishnan K, Marrie T, Rolfson D et al. Gaps in patient care practices to prevent hospital-acquired delirium. Can Fam Physician. 2009. 55:e41-6. [QxMD MEDLINE Link].
Neto AS, Nassar AP Jr, Cardoso SO, Manetta JA, Pereira VG, Espósito DC, et al. Delirium screening in critically ill patients: A systematic review and meta-analysis. Crit Care Med. 2012 Jun. 40(6):1946-51. [QxMD MEDLINE Link].
Inouye SK, Kosar CM, Tommet D, et al. The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med. 2014 Apr 15. 160(8):526-33. [QxMD MEDLINE Link].
Brooks M. New scoring tool gauges severity of delirium. Medscape Medical News. April 15, 2014. [Full Text].
Rudolph JL, Jones RN, Rasmussen LS, Silverstein JH, Inouye SK, Marcantonio ER. Independent vascular and cognitive risk factors for postoperative delirium. Am J Med. 2007 Sep. 120(9):807-13. [QxMD MEDLINE Link].
Perry SW. Organic mental disorders caused by HIV: update on early diagnosis and treatment. Am J Psychiatry. 1990 Jun. 147(6):696-710. [QxMD MEDLINE Link].
Van Muster BC, Korevaar JC, Korse CM , Bonfer JM, Zwinderman AH, DeRooji SE. Serum S 100B in elderly patients with and without delirium. International Journal of Geriatric Psychiatry. 2010. 25(3):234-239.
Van Rompaey B, Elseviers M M, Van Drom W, Fromont V, Jorens P G. The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients. Critical Care. 2012. 16:
Martinez F, Tobar C, Hill N. Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature. Age Ageing. 2015 Mar. 44 (2):196-204. [QxMD MEDLINE Link].
Kishi T, Hirota T, Matsunaga S, Iwata N. Antipsychotic medications for the treatment of delirium: a systematic review and meta-analysis of randomised controlled trials. J Neurol Neurosurg Psychiatry. 2015 Sep 4. [QxMD MEDLINE Link].
Neufeld KJ, Yue J, Robinson TN, Inouye SK, Needham DM. Antipsychotic Medication for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta-Analysis. J Am Geriatr Soc. 2016 Apr. 64 (4):705-14. [QxMD MEDLINE Link].
Overshott R, Karim S, Burns A. Cholinesterase inhibitors for delirium. Cochrane Database Syst Rev. 2008 Jan 23. CD005317. [QxMD MEDLINE Link].
van Eijk MM, Roes KC, Honing ML, Kuiper MA, Karakus A, van der Jagt M. Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: a multicentre, double-blind, placebo-controlled randomised trial. Lancet. 2010 Nov 27. 376(9755):1829-37. [QxMD MEDLINE Link].
Tampi RR, Tampi DJ, Ghori AK. Acetylcholinesterase Inhibitors for Delirium in Older Adults. Am J Alzheimers Dis Other Demen. 2016 Jun. 31 (4):305-10. [QxMD MEDLINE Link].
Mundigler G, Delle- Karth G, Koreny M et al. Circadian rhythm of melatonin secretion in sedated critically ill patients with severe sepsis. Crit Care Med. 2002. 30:536-540. [QxMD MEDLINE Link].
Alagiakrishnan K. Melatonin based therapies for delirium and dementia. Discov Med. May 2016. 21(117):363-371. [QxMD MEDLINE Link].
Anderson CP, Ngo LH, Marcantonio ER. Complications in Postacute Care Are Associated with Persistent Delirium. J Am Geriatr Soc. 2012 May 30. [QxMD MEDLINE Link].
Maclullich AMJ, Beaglehole A, Hall RA, Meagher DJ. Delirium and long-term cognitive impairment. International Review of Psychiatry. 2009. 21(1):30-42.
Alagiakrishnan K, Marrie T, Rolfson D, Coke W, Camicioli R, Duggan D. Simple cognitive testing (Mini-Cog) predicts in-hospital delirium in the elderly. J Am Geriatr Soc. 2007 Feb. 55(2):314-6. [QxMD MEDLINE Link].
Alagiakrishnan K, Wiens CA. An approach to drug induced delirium in the elderly. Postgrad Med J. 2004 Jul. 80(945):388-93. [QxMD MEDLINE Link].
Alsop DC, Fearing MA, Johnson K, Sperling R, Fong TG, Inouye SK. The role of neuroimaging in elucidating delirium pathophysiology. J Gerontol A Biol Sci Med Sci. 2006 Dec. 61(12):1287-93. [QxMD MEDLINE Link].
Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med. 2001. 27:859-864.
Chan D, Brennan NJ. Delirium: making the diagnosis, improving the prognosis. Geriatrics. 1999 Mar. 54(3):28-30, 36, 39-42. [QxMD MEDLINE Link].
Day JJ, Bayer AJ, McMahon M. Thiamine status, vitamin supplements and postoperative confusion. Age Ageing. 1988 Jan. 17(1):29-34. [QxMD MEDLINE Link].
Ely EW, Inouye SK, Bernard GR. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001 Dec 5. 286(21):2703-10. [QxMD MEDLINE Link].
Henderson D. Delirium: Common Treatment No Better Than Placebo. Medscape Medical News. Available at http://www.medscape.com/viewarticle/810031.. Accessed: September 5, 2013.
Hung OL, Lewin NA, Howland MA. Herbal preparations. Goldfrank LR, Flomenbaum NE, Lewin NA, et al, eds. Goldfrank's Toxicologic Emergencies. 7th ed. New York: McGraw-Hill; 2002. 1129.
Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med. 1994 Sep. 97(3):278-88. [QxMD MEDLINE Link].
Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999 Mar 4. 340(9):669-76. [QxMD MEDLINE Link].
Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. 1996 Mar 20. 275(11):852-7. [QxMD MEDLINE Link].
Jones RN, Yang FM, Zhang Y, Kiely DK, Marcantonio ER, Inouye SK. Does educational attainment contribute to risk for delirium? A potential role for cognitive reserve. J Gerontol A Biol Sci Med Sci. 2006 Dec. 61(12):1307-11. [QxMD MEDLINE Link].
Leslie DL, Zhang Y, Holford TR, Bogardus ST, Leo- Summers LS, Inouye SK. Premature death associated with delirium at 1-year follow-up. Arch Intern Med. 2005 July. 165(14):1657-62. [QxMD MEDLINE Link].
Lipowski ZJ. Delirium (acute confusional states). JAMA. 1987 Oct 2. 258(13):1789-92. [QxMD MEDLINE Link].
Lipowski ZJ. Delirium in the elderly patient. N Engl J Med. 1989 Mar 2. 320(9):578-82. [QxMD MEDLINE Link].
Liptzin B, Levkoff SE. An empirical study of delirium subtypes. Br J Psychiatry. 1992 Dec. 161:843-5. [QxMD MEDLINE Link].
Liptzin B, Levkoff SE, Gottlieb GL. Delirium. J Neuropsychiatry Clin Neurosci. 1993 Spring. 5(2):154-60. [QxMD MEDLINE Link].
McAvay GJ, Van Ness PH, Bogardus ST Jr, Zhang Y, Leslie DL, Leo-Summers LS. Depressive symptoms and the risk of incident delirium in older hospitalized adults. J Am Geriatr Soc. 2007 May. 55(5):684-91. [QxMD MEDLINE Link].
O'Keeffe ST, Ni Chonchubhair A. Postoperative delirium in the elderly. Br J Anaesth. 1994 Nov. 73(5):673-87. [QxMD MEDLINE Link].
O'Keeffee ST. Delirium in the elderly. Age Ageing. 1999 Sep. 28 Suppl 2:5-8. [QxMD MEDLINE Link].
Obrecht R, Okhomina FO, Scott DF. Value of EEG in acute confusional states. J Neurol Neurosurg Psychiatry. 1979 Jan. 42(1):75-7. [QxMD MEDLINE Link].
Otter H, Martin J, Bäsell K, von Heymann C, Hein OV, Böllert P. Validity and reliability of the DDS for severity of delirium in the ICU. Neurocrit Care. 2005. 2(2):150-8. [QxMD MEDLINE Link].
Ouimet S, Riker R, Bergeon N, Cosette M, Kavanagh B, Skrobik Y. Subsyndromal delirium in the ICU: evidence for a disease spectrum. Intensive Care Med. 2007 Apr 3. 33(6):1007-1013. [QxMD MEDLINE Link].
Page VJ, Ely EW, Gates S, et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Respir Med. 2013 Aug 21.
Sipahimalani A, Masand PS. Use of risperidone in delirium: case reports. Ann Clin Psychiatry. 1997 Jun. 9(2):105-7. [QxMD MEDLINE Link].
Teslyar P, Stock VM, Wilk CM, Camsari U, Ehrenreich MJ, Himelhoch S. Prophylaxis with Antipsychotic Medication Reduces the Risk of Post-Operative Delirium in Elderly Patients: A Meta-Analysis. Psychosomatics. 2013 Feb 1. [QxMD MEDLINE Link].
Trzepacz PT. Delirium. Advances in diagnosis, pathophysiology, and treatment. Psychiatr Clin North Am. 1996 Sep. 19(3):429-48. [QxMD MEDLINE Link].
Matthews FE, Arthur A, Barnes LE, Bond J, Jagger C, Robinson L, et al. A two-decade comparison of prevalence of dementia in individuals aged 65 years and older from three geographical areas of England: results of the Cognitive Function and Ageing Study I and II. Lancet. 2013 Oct 26. 382 (9902):1405-12. [QxMD MEDLINE Link].
Davis D, Searle SD, Tsui A. The Scottish Intercollegiate Guidelines Network: risk reduction and management of delirium. Age Ageing. 2019 Mar 30. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

Kannayiram Alagiakrishnan, MD, MBBS, MPH, MHA Professor, Department of Medicine, Division of Geriatric Medicine, University of Alberta Faculty of Medicine and Dentistry, Canada

Kannayiram Alagiakrishnan, MD, MBBS, MPH, MHA is a member of the following medical societies: American College of Physicians, American Geriatrics Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Glen L Xiong, MD Associate Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California, Davis, School of Medicine; Medical Director, Sacramento County Mental Health Treatment Center

Glen L Xiong, MD is a member of the following medical societies: AMDA - The Society for Post-Acute and Long-Term Care Medicine, American College of Physicians, American Psychiatric Association, Central California Psychiatric Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: SafelyYou, Blue Cross Blue Shield<br/>book co-editor for: Wolter Kluwer, American Psychiatric Publishing Inc.

Additional Contributors

Mohammed A Memon, MD Psychiatrist/Geriatric Psychiatrist, Carolina Center for Behavioral Health; Assistant Professor of Psychiatry, Virginia Commonwealth University School of Medicine

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, American Psychiatric Association

Disclosure: Nothing to disclose.

Acknowledgements

Patricia Blanchette, MD Department Chair and Director, Geriatric Medicine Fellowship Program, Professor of Geriatric Medicine, John A Burns School of Medicine, University of Hawaii

Patricia Blanchette, MD is a member of the following medical societies: American College of Physicians, American Geriatrics Society, American Medical Association, American Medical Directors Association, Gerontological Society of America, and Hawaii Medical Association

Disclosure: Nothing to disclose.

Sections Delirium
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Guidelines
Medication
Follow-up
Questions & Answers
Tables
References

Features	Delirium	Dementia
Onset	Acute	Insidious
Course	Fluctuating	Progressive
Duration	Days to weeks	Months to years
Consciousness	Altered	Clear
Attention	Impaired	Normal, except in severe dementia
Psychomotor changes	Increased or decreased	Often normal
Reversibility	Usually	Rarely

Delirium Guidelines

Guidelines Summary

Scottish Intercollegiate Guidelines Network

References

Tables

Contributor Information and Disclosures

What would you like to print?