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Delirium

Updated : December 26, 2023





Background

Delirium is a medical condition characterized by an acute and fluctuating disturbance in attention and awareness that develops over a short period of time, typically hours to days. It is often accompanied by changes in perception, thinking, and behavior. It is usually caused by an underlying medical condition and is not attributable to an existing neurocognitive disorder.

The factors that trigger delirium can be diverse and may include any condition that disrupts the body’s normal functioning in vulnerable patients. How a person presents clinically can differ, often showing changes in their psychomotor behavior, such as being overly active or underactive and experiencing problems with their sleep patterns, including both the amount and quality of sleep.

Epidemiology

Delirium is more prevalent among elderly individuals and is a common complication following surgery, particularly high-risk procedures, with reported incidence rates ranging from 10 to 50% respectively. Postoperative delirium is linked to a higher risk of mortality within 30 days by 10% and can prolong hospital stays.

In the general population, delirium is associated with increased healthcare utilization, complications, and poor outcomes, and is estimated to contribute to a total healthcare cost of $164 billion per year. Patients who present to the emergency department with delirium have a 70% higher mortality risk at six months, and ICU patients with delirium have a 2-4 times greater risk of overall mortality.

Anatomy

Pathophysiology

Delirium is a complex condition with no single cause for its development. Instead, it is believed to arise from a combination of factors. Aging processes can reduce the body’s ability to cope with physical stress, as seen in diminished brain blood flow, neuron loss, and changes in stress-regulating neurotransmitters.

Inflammatory insults to the body can damage the blood-brain barrier, leading to further inflammation, ischemia, and neuronal death. Disrupted sleep patterns and altered melatonin secretion can also contribute to delirium, as melatonin plays a role in many vital brain functions, such as regulating sleep, glucose, body temperature, and immune response.

Delirium is associated with changes in acetylcholine and dopamine activity, two closely linked neurotransmitters necessary for proper brain function. Finally, physiologic stress can trigger the release of glucocorticoids, which can increase neuronal vulnerability and affect gene regulation, cellular signaling, and glial cell behavior.

Etiology

Delirium has two groups of risk factors predisposing and precipitating factors. Predisposing factors include advanced age, dementia, functional impairments, male gender, impaired senses, alcohol use disorder, mild cognitive impairment, and laboratory abnormalities. Precipitating factors vary, but drug side effects are responsible for up to 39% of delirium cases.

Additional precipitating factors are anesthesia, surgery, infections, hypoxia, acute illness, chronic illness exacerbation, and untreated pain. Even minor disturbances such as dehydration , constipation, urinary retention, sleep deprivation, or minor medical procedures can trigger delirium in highly vulnerable patients, such as those with advanced dementia.

Genetics

Prognostic Factors

Clinical History

Clinical History

Delirium is characterized by a sudden onset of confusion, disorientation, and changes in perception, cognition, and behavior. Delirium can be classified into three subtypes: hyperactive, hypoactive, and mixed. Hyperactive delirium is the most common subtype characterized by restlessness, increased agitation, and sympathetic activity. Patients with hyperactive delirium have history of delusions, hallucinations, and occasionally uncooperative or combative behavior. They may also experience insomnia and have difficulty staying still or focusing on tasks.

Hypoactive delirium, conversely, is characterized by decreased arousal and somnolence. Patients with hypoactive delirium may appear lethargic or unresponsive and have difficulty staying awake or engaged in conversations or activities. Hypoactive delirium can be particularly dangerous as it is often unrecognized or mistaken for fatigue or depression, and it is associated with higher morbidity and mortality rates. Patients with delirium can also fluctuate between hyperactive and hypoactive presentations, making diagnosis and management challenging.

Delirium is characterized by a sudden onset of confusion, disorientation, and changes in perception, cognition, and behavior. Delirium can be classified into three subtypes: hyperactive, hypoactive, and mixed. Hyperactive delirium is the most common subtype characterized by restlessness, increased agitation, and sympathetic activity. Patients with hyperactive delirium have history of delusions, hallucinations, and occasionally uncooperative or combative behavior. They may also experience insomnia and have difficulty staying still or focusing on tasks.

Hypoactive delirium, conversely, is characterized by decreased arousal and somnolence. Patients with hypoactive delirium may appear lethargic or unresponsive and have difficulty staying awake or engaged in conversations or activities. Hypoactive delirium can be particularly dangerous as it is often unrecognized or mistaken for fatigue or depression, and it is associated with higher morbidity and mortality rates. Patients with delirium can also fluctuate between hyperactive and hypoactive presentations, making diagnosis and management challenging.

Physical Examination

Physical Examination

The initial step in evaluating and treating delirium involves detecting its presence, which can be challenging since up to 60% of cases may go unrecognized. While hyperactive delirium is easier to detect due to the patient’s disruptive behavior, hypoactive delirium often goes undetected as patients exhibit less disruptive behavior.

Symptoms of hypoactive delirium include increased irritation and sympathetic activity, hallucinations, delusions, and sometimes uncooperative or combative behavior. Patients with hypoactive delirium also experience increased somnolence and decreased stimulation. This form of delirium is particularly dangerous because it is often mistaken for fatigue or depression and can be associated with higher rates of morbidity and mortality. Patients may also experience fluctuation between hyperactive and hypoactive presentations.

The individual experiences a sudden onset of cognitive changes characterized by a fluctuating pattern. They need help maintaining attention and following conversations. Additionally, they have disorganized thinking, which may manifest as memory, orientation, or language issues. There is also a notable shift in their level of consciousness, which may result in hypervigilance, drowsiness, or even a state of stupor.

 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Differential Diagnosis

Coma

Depression

Catatonia

Dementia

Paranoia

Psychosis

Nonconvulsive status epilepticus

Central nervous system malignancy

 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

While there are currently no FDA-approved medications for treating or preventing delirium, several non-pharmacologic interventions can be highly effective in managing this condition. Prevention is often the most effective approach to treating delirium. It is crucial to identify patients at high risk for developing delirium and take steps to prevent its occurrence. Some risk factors are not modifiable, such as age and underlying neurodegenerative disorders like dementia. However, several modifiable risk factors, such as infections, medications, environmental factors, and reduced sensory response, can be addressed.

Medications, especially those with sedative or psychoactive properties, can be a significant risk factor for delirium. Infections, such as urinary tract infections, can also increase the risk of delirium. Therefore, early detection and treatment of infections are essential in preventing delirium. Environmental factors, such as noise, bright lights, and disruptions to sleep, can also contribute to the development of delirium. Reduced sensory input, such as limited visual or auditory stimulation, can also increase the risk of delirium.

While it is important to prioritize prevention and nonpharmacologic interventions for the management of delirium, there may be circumstances where pharmacologic therapies are necessary. For instance, patients experiencing delirium due to substance withdrawal may require benzodiazepines to manage alcohol withdrawal. Pharmacologic interventions may also be necessary in cases of delirium at the end of life to relieve pain and improve quality of life.

However, there is no recommended pharmacologic treatment for hypoactive delirium. In situations where hyperactive delirium poses a threat to the patient or others, antipsychotics are the preferred first-line treatment unless they are contraindicated due to other comorbidities. Commonly used antipsychotics for delirium include haloperidol, risperidone, and quetiapine, depending on the patient’s underlying conditions and side effect profiles.

For instance, quetiapine may be preferred over haloperidol in patients with Parkinson’s disease. It is crucial to monitor patients’ QTc interval with an electrocardiogram when administering antipsychotics, as these medications may cause QTc prolongation. Additionally, antipsychotic doses should be optimized and adjusted daily until they are no longer necessary. The underlying cause of delirium should also be treated with necessary medications, such as antibiotics, in the case of infections.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Medication

 

droperidol

5

mg

Solution

Intramuscular (IM)

as needed



droperidol 

(Off-label)
5 mg intramuscularly



droperidol 

(Off-label)
5 mg intramuscularly
Dose Modification
In the case of renal or hepatic impairment, use the drug with caution. Safety and efficacy are not seen in these cases



 
 

Media Gallary

References

https://www.ncbi.nlm.nih.gov/books/NBK470399/

Delirium

Updated : December 26, 2023




Delirium is a medical condition characterized by an acute and fluctuating disturbance in attention and awareness that develops over a short period of time, typically hours to days. It is often accompanied by changes in perception, thinking, and behavior. It is usually caused by an underlying medical condition and is not attributable to an existing neurocognitive disorder.

The factors that trigger delirium can be diverse and may include any condition that disrupts the body’s normal functioning in vulnerable patients. How a person presents clinically can differ, often showing changes in their psychomotor behavior, such as being overly active or underactive and experiencing problems with their sleep patterns, including both the amount and quality of sleep.

Delirium is more prevalent among elderly individuals and is a common complication following surgery, particularly high-risk procedures, with reported incidence rates ranging from 10 to 50% respectively. Postoperative delirium is linked to a higher risk of mortality within 30 days by 10% and can prolong hospital stays.

In the general population, delirium is associated with increased healthcare utilization, complications, and poor outcomes, and is estimated to contribute to a total healthcare cost of $164 billion per year. Patients who present to the emergency department with delirium have a 70% higher mortality risk at six months, and ICU patients with delirium have a 2-4 times greater risk of overall mortality.

Delirium is a complex condition with no single cause for its development. Instead, it is believed to arise from a combination of factors. Aging processes can reduce the body’s ability to cope with physical stress, as seen in diminished brain blood flow, neuron loss, and changes in stress-regulating neurotransmitters.

Inflammatory insults to the body can damage the blood-brain barrier, leading to further inflammation, ischemia, and neuronal death. Disrupted sleep patterns and altered melatonin secretion can also contribute to delirium, as melatonin plays a role in many vital brain functions, such as regulating sleep, glucose, body temperature, and immune response.

Delirium is associated with changes in acetylcholine and dopamine activity, two closely linked neurotransmitters necessary for proper brain function. Finally, physiologic stress can trigger the release of glucocorticoids, which can increase neuronal vulnerability and affect gene regulation, cellular signaling, and glial cell behavior.

Delirium has two groups of risk factors predisposing and precipitating factors. Predisposing factors include advanced age, dementia, functional impairments, male gender, impaired senses, alcohol use disorder, mild cognitive impairment, and laboratory abnormalities. Precipitating factors vary, but drug side effects are responsible for up to 39% of delirium cases.

Additional precipitating factors are anesthesia, surgery, infections, hypoxia, acute illness, chronic illness exacerbation, and untreated pain. Even minor disturbances such as dehydration , constipation, urinary retention, sleep deprivation, or minor medical procedures can trigger delirium in highly vulnerable patients, such as those with advanced dementia.

Clinical History

Delirium is characterized by a sudden onset of confusion, disorientation, and changes in perception, cognition, and behavior. Delirium can be classified into three subtypes: hyperactive, hypoactive, and mixed. Hyperactive delirium is the most common subtype characterized by restlessness, increased agitation, and sympathetic activity. Patients with hyperactive delirium have history of delusions, hallucinations, and occasionally uncooperative or combative behavior. They may also experience insomnia and have difficulty staying still or focusing on tasks.

Hypoactive delirium, conversely, is characterized by decreased arousal and somnolence. Patients with hypoactive delirium may appear lethargic or unresponsive and have difficulty staying awake or engaged in conversations or activities. Hypoactive delirium can be particularly dangerous as it is often unrecognized or mistaken for fatigue or depression, and it is associated with higher morbidity and mortality rates. Patients with delirium can also fluctuate between hyperactive and hypoactive presentations, making diagnosis and management challenging.

Delirium is characterized by a sudden onset of confusion, disorientation, and changes in perception, cognition, and behavior. Delirium can be classified into three subtypes: hyperactive, hypoactive, and mixed. Hyperactive delirium is the most common subtype characterized by restlessness, increased agitation, and sympathetic activity. Patients with hyperactive delirium have history of delusions, hallucinations, and occasionally uncooperative or combative behavior. They may also experience insomnia and have difficulty staying still or focusing on tasks.

Hypoactive delirium, conversely, is characterized by decreased arousal and somnolence. Patients with hypoactive delirium may appear lethargic or unresponsive and have difficulty staying awake or engaged in conversations or activities. Hypoactive delirium can be particularly dangerous as it is often unrecognized or mistaken for fatigue or depression, and it is associated with higher morbidity and mortality rates. Patients with delirium can also fluctuate between hyperactive and hypoactive presentations, making diagnosis and management challenging.

Physical Examination

The initial step in evaluating and treating delirium involves detecting its presence, which can be challenging since up to 60% of cases may go unrecognized. While hyperactive delirium is easier to detect due to the patient’s disruptive behavior, hypoactive delirium often goes undetected as patients exhibit less disruptive behavior.

Symptoms of hypoactive delirium include increased irritation and sympathetic activity, hallucinations, delusions, and sometimes uncooperative or combative behavior. Patients with hypoactive delirium also experience increased somnolence and decreased stimulation. This form of delirium is particularly dangerous because it is often mistaken for fatigue or depression and can be associated with higher rates of morbidity and mortality. Patients may also experience fluctuation between hyperactive and hypoactive presentations.

The individual experiences a sudden onset of cognitive changes characterized by a fluctuating pattern. They need help maintaining attention and following conversations. Additionally, they have disorganized thinking, which may manifest as memory, orientation, or language issues. There is also a notable shift in their level of consciousness, which may result in hypervigilance, drowsiness, or even a state of stupor.

 

Differential Diagnosis

Coma

Depression

Catatonia

Dementia

Paranoia

Psychosis

Nonconvulsive status epilepticus

Central nervous system malignancy

 

While there are currently no FDA-approved medications for treating or preventing delirium, several non-pharmacologic interventions can be highly effective in managing this condition. Prevention is often the most effective approach to treating delirium. It is crucial to identify patients at high risk for developing delirium and take steps to prevent its occurrence. Some risk factors are not modifiable, such as age and underlying neurodegenerative disorders like dementia. However, several modifiable risk factors, such as infections, medications, environmental factors, and reduced sensory response, can be addressed.

Medications, especially those with sedative or psychoactive properties, can be a significant risk factor for delirium. Infections, such as urinary tract infections, can also increase the risk of delirium. Therefore, early detection and treatment of infections are essential in preventing delirium. Environmental factors, such as noise, bright lights, and disruptions to sleep, can also contribute to the development of delirium. Reduced sensory input, such as limited visual or auditory stimulation, can also increase the risk of delirium.

While it is important to prioritize prevention and nonpharmacologic interventions for the management of delirium, there may be circumstances where pharmacologic therapies are necessary. For instance, patients experiencing delirium due to substance withdrawal may require benzodiazepines to manage alcohol withdrawal. Pharmacologic interventions may also be necessary in cases of delirium at the end of life to relieve pain and improve quality of life.

However, there is no recommended pharmacologic treatment for hypoactive delirium. In situations where hyperactive delirium poses a threat to the patient or others, antipsychotics are the preferred first-line treatment unless they are contraindicated due to other comorbidities. Commonly used antipsychotics for delirium include haloperidol, risperidone, and quetiapine, depending on the patient’s underlying conditions and side effect profiles.

For instance, quetiapine may be preferred over haloperidol in patients with Parkinson’s disease. It is crucial to monitor patients’ QTc interval with an electrocardiogram when administering antipsychotics, as these medications may cause QTc prolongation. Additionally, antipsychotic doses should be optimized and adjusted daily until they are no longer necessary. The underlying cause of delirium should also be treated with necessary medications, such as antibiotics, in the case of infections.

droperidol

5

mg

Solution

Intramuscular (IM)

as needed



droperidol 

(Off-label)
5 mg intramuscularly



droperidol 

(Off-label)
5 mg intramuscularly
Dose Modification
In the case of renal or hepatic impairment, use the drug with caution. Safety and efficacy are not seen in these cases



https://www.ncbi.nlm.nih.gov/books/NBK470399/

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