complete.
Literature review current through: Oct 2018. | This topic last updated: Aug 22, 2014.
INTRODUCTION — Delirium and confusional states are among the most common mental
disorders encountered in patients with medical illness, particularly among those who are
older. They are associated with many complex underlying medical conditions and can be
hard to recognize. Systematic studies and clinical trials are difficult to perform in patients
with cognitive impairment. Recommendations for evaluating and treating delirium are
based primarily upon clinical observation and expert opinion [1].
●Disturbance in attention (reduced ability to direct, focus, sustain, and shift attention)
and awareness.
●The disturbance develops over a short period of time (usually hours to days),
represents a change from baseline, and tends to fluctuate during the course of the
day.
●There is evidence from the history, physical examination, or laboratory findings that
the disturbance is caused by a medical condition, substance intoxication or
withdrawal, or medication side effect.
Additional features that may accompany delirium and confusion include the following:
●Psychomotor behavioral disturbances such as hypoactivity, hyperactivity with
increased sympathetic activity, and impairment in sleep duration and architecture.
There is no generally accepted consensus regarding the distinction between delirium and
confusional states. The terms "acute confusional state" and "encephalopathy" are often
used synonymously with delirium. The more general term "confusion" is used to indicate a
problem with coherent thinking. Confused patients are unable to think with normal speed,
clarity, or coherence [3]. Confusion is typically associated with a depressed sensorium and
a reduced attention span, and it is an essential component of delirium.
The term "acute confusional state" refers to an acute state of altered consciousness
characterized by disordered attention along with diminished speed, clarity, and coherence
of thought [3]. Although this definition encompasses delirium as well, some experts use
"confusional state" to convey the additional meaning of reduced alertness and altered
psychomotor activity [3]. In this paradigm, delirium is a special type of confusional state
characterized by increased vigilance, with psychomotor and autonomic overactivity; the
delirious patient displays agitation, excitement, tremulousness, hallucinations, fantasies,
and delusions.
In this discussion, the term delirium will be used in the sense of the DSM-V definition. The
additional components of agitation, tremor, and hallucinations are allowed for but are not
essential diagnostic features of delirium in the DSM-V usage. Confusion and other states
of altered consciousness are encompassed by the DSM-V definition of delirium.
In general, delirium can be found wherever there are sick patients. When standardized
screening and diagnostic tools (see 'Evaluation' below) have been applied prospectively to
consecutive patients, high rates of delirium have been demonstrated in intensive care units
(70 percent) [7], emergency departments (10 percent) [8], hospice units (42 percent) [9],
and postacute care settings (16 percent) [10]. Now that the care of sicker patients has
become fragmented across a variety of venues, clinicians are challenged to identify and
manage delirium efficiently across a wide variety of settings.
Despite these limitations, some important data regarding the pathophysiology of delirium
have been reported. Risk factors for the development of delirium have also been identified.
●Arousal and attention may be disrupted by brain lesions involving the ascending
reticular activating system (ARAS) from the mid-pontine tegmentum rostrally to the
anterior cingulate regions.
●Attention in both right and left aspects of extrapersonal space is governed by the
"nondominant" parietal and frontal lobes. Thus with inattention, there is typically some
disruption of the integrated function of these regions.
●Insight and judgment are dependent on intact higher order integrated cortical
function. Since insight into perceptions is often reduced with delirium and confusional
states, it seems likely that higher order cortical function is therefore impaired,
especially regarding frontal lobe involvement in scrutinizing incoming sensory
information.
The results of brainstem auditory evoked potential, somatosensory evoked potentials, and
neuroimaging studies have supported an important role for subcortical (eg, thalamus,
basal ganglia, and pontine reticular formation) as well as cortical structures in the
pathogenesis of delirium [12]. These findings correlate with clinical reports that patients
with subcortical strokes and basal ganglia abnormalities (including Parkinson disease)
have a higher susceptibility to delirium.
Neurotransmitter and humoral mechanisms — Acetylcholine plays a key role in the
pathogenesis of delirium [13,14]. Anticholinergic drugs cause delirium when given to
healthy volunteers and are even more likely to lead to acute confusion in frail elderly
persons. This effect can be reversed with cholinesterase inhibitors such as physostigmine.
(See "Anticholinergic poisoning".)
Further support for the role of acetylcholine is derived from observations that medical
conditions precipitating delirium, such as hypoxia, hypoglycemia, and thiamine deficiency,
decrease acetylcholine synthesis in the central nervous system (CNS). In addition, serum
anticholinergic activity, measured with binding assays employing purified preparations of
brain muscarinic receptors, correlates with the severity of delirium in postoperative and
medical patients [13,15]. Finally, Alzheimer disease, which is characterized by a loss of
cholinergic neurons, increases the risk of delirium due to anticholinergic medications.
The anticholinergic mechanism is important for clinicians to keep in mind, since many
drugs used by older adults (including several not traditionally viewed to have
"anticholinergic effects") can lead to detectable serum anticholinergic activity measured by
competitive radioreceptor binding [16,17]. Psychotropic drugs, in particular, are likely to
cause detectable serum anticholinergic activity at doses typically administered to older
patients. Some elderly patients with delirium also have elevated serum anticholinergic
activity in the absence of anticholinergic drug use, raising the possibility that endogenous
anticholinergic substances may play a role in delirium [13].
Drugs that are agonists or antagonists of a number of other neurotransmitters can produce
delirium-like effects, although the precise role of these neurotransmitter systems is difficult
to determine. Cerebrospinal fluid (CSF) studies of patients with delirium reveal alterations
in neuropeptides (eg, somatostatin), endorphins, serotonin, norepinephrine, and GABA,
among others [12]. However, it is difficult to exclude the confounding effects of underlying
illness or dementia.
Pro-inflammatory cytokines such as interleukins and tumor necrosis factor alpha also may
have a role in the pathogenesis of delirium. These agents have strong CNS effects when
injected into experimental animals or when administered for therapeutic purposes (eg,
interferons in chronic hepatitis). Cytokine activation may account for delirium (particularly
hyperactive forms of the disturbance) in situations such as sepsis (where mental changes
may actually precede fever), cardiopulmonary bypass [18], and acute hip fracture [19].
Risk factors — Delirium is a multifactorial disorder. Factors that increase the risk for
delirium and confusional states can be classified into those that increase baseline
vulnerability and those that precipitate the disturbance [20].
The most commonly identified risk factors are underlying brain diseases such as dementia,
stroke, or Parkinson disease; these are present in nearly one-half of older patients with
delirium. In a meta-analysis of published prospective studies of delirium, the prevalence of
delirium superimposed upon dementia ranged from 22 to 89 percent [21]. Often, the
dementia went unrecognized prior to the onset of delirium. Similarly, in a study of 78
elderly patients with femoral neck fractures who were followed for five years, dementia
developed in 69 percent of the 29 patients with postoperative delirium versus only 20
percent of the 49 patients without postoperative delirium [22].
Other factors that increase the vulnerability to delirium include advanced age and sensory
impairment.
Precipitating factors — Factors that may precipitate delirium are numerous and varied
(table 1). Some common examples include polypharmacy (particularly psychoactive
drugs), infection, dehydration, immobility (including restraint use), malnutrition, and the use
of bladder catheters. Drugs that may precipitate delirium and confusion are noted in the
Table (table 2).
Patients will appear obviously drowsy, lethargic, or even semi-comatose in more advanced
cases of delirium. The opposite extreme, hypervigilance, may also occur in cases of
alcohol or sedative drug withdrawal, but such a presentation is less common in older
persons. (See "Management of moderate and severe alcohol withdrawal syndromes".)
A variety of language difficulties can occur. Patients may lose the ability to write or to
speak a second language. One personal experience involved a patient who immigrated to
North America as an adolescent; she spoke only Italian during her delirium, recovering her
grasp of English after her pneumonia was treated.
Temporal course — Delirium develops over hours to days and typically persists for days
to months. The acuteness of the presentation is the most helpful feature in differentiating
delirium from dementia. In addition, the features of delirium are unstable, typically
becoming most severe in the evening and at night. It is not unusual for a patient with
delirium to appear relatively lucid during morning rounds. Clinicians, particularly
physicians, are apt to miss the diagnosis if they rely upon only a single point assessment;
evidence of the behavior change should be actively solicited from all staff, especially those
working evening and night shifts.
There is often a prodromal phase, especially in elderly patients, that later blends
into quiet/hypoactive delirium or erupts into an agitated confusional state. Prodromal
features include complaints of fatigue, sleep disturbance (excessive daytime somnolence
or insomnia), depression, anxiety, restlessness, irritability and hypersensitivity to light or
sound. With progression there are perceptual disturbances and cognitive impairment.
These symptoms may fluctuate. Hypoactive delirium can, however, begin without a
prodromal phase and agitated behavior may appear as the first manifestation of delirium
without a prodromal or hypoactive phase.
Elderly patients — Patients with delirium are sick by definition. However, older patients
with delirium often do not look sick apart from their behavioral change. Thus, delirium may
be the only finding suggesting acute illness in older demented patients. Caregivers must
be educated that sudden changes in mental functioning are not expected with most
progressive dementias and require prompt medical attention.
Other features — Delirium may present with a variety of clinical manifestations that are
not essential diagnostic features, including psychomotor agitation, sleep-wake reversals,
irritability, anxiety, emotional lability, and hypersensitivity to lights and sounds. These
features are not seen in all patients with delirium and can be evident in patients with
dementia; their presence neither rules in nor rules out the diagnosis. The most common
presentation in older patients is a relatively quiet, withdrawn state that frequently is
mistaken for depression.
The relationship between clinical manifestations and outcome has not been well studied,
although a report of outcomes of delirium following hip fracture repair suggested that
patients with more severe delirium, including psychomotor agitation, had higher rates of
mortality and nursing home placement [23]. Delirium that does not resolve before
discharge is also a risk factor for nursing home placement [24].
EVALUATION — There are two important aspects to the diagnostic evaluation of delirium:
recognizing that the disorder is present and uncovering the underlying medical illness that
has caused delirium.
Clinical confirmation — The DSM-V criteria (See 'Definition and terminology' above.)
form a practical framework for assessing delirium [25]:
●A change in the level of consciousness is often the first observable clue. Clinicians
must not "normalize" lethargy or somnolence by assuming that illness, sleep loss,
fatigue, or anxiety are causing the changes.
●In cases where the patient appears awake, the ability to focus, sustain, or shift
attention can be assessed during attempts to obtain a history; a global assessment of
the patient's "accessibility" during conversation or the performance of a mental status
examination is a sensitive indicator of delirium.
●Conversation with the patient may elicit memory difficulties, disorientation, or speech
that is tangential, disorganized, or incoherent. The clinician should be aware of
superficially appropriate conversation that follows social norms but is poor in content.
●When in doubt, formal mental status testing should be performed, such as the Mini-
Mental State Examination or brief bedside tests of attention (table 3). Serial-sevens
and spelling a word such as “farm” or “world” backward are other simple tests of
attention. (See "Evaluation of cognitive impairment and dementia", section on 'Mini-
Mental State Examination'.)
Determining that cognitive impairment or perceptual problems are not due to a prior or
progressing dementia can be challenging and requires knowledge of the patient's baseline
level of functioning. The diagnosis is made more easily if there has been a prior
assessment of cognitive abilities. In other instances, informants must be immediately
sought to establish chronology. These should include formal caregivers (eg, nursing staff
familiar with the patient), family members, and informal caregivers, particularly those who
may have observed fluctuations in the patient's mental functions.
History — Some historical clues to the underlying etiology of delirium and confusion can
be obtained from relatives, eg, recent febrile illness, history of organ failure, a medication
list, history of alcoholism or drug abuse, or recent depression. It is otherwise often difficult
to impossible to obtain a history in the confused or uncooperative patient. As an example,
myocardial infarction may cause sufficient confusion that the patient cannot relate a history
of chest pain.
The patient's general appearance may be suggestive, eg, the dusky appearance seen with
chronic pulmonary disease, the jaundiced appearance of hepatic failure, or the stigmata of
renal failure. Needle tracks strongly suggest drug abuse. Cherry-red lips indicate possible
carbon monoxide poisoning. The breath may smell of alcohol, fetor hepaticus, uremic fetor
or ketones. Hyperventilation offers a limited number of possible etiologies.
(See 'Diagnostic tests' below.)
Pitfalls in the examination must be kept in mind: temperature may be under 38.3ºC (101ºF)
even in the presence of serious infections; auscultatory and radiographic findings of
pneumonia may be subtle or absent; and abdominal catastrophes may present without
peritoneal signs in frail older patients. False-positive findings occur as well (eg, nuchal
rigidity may not signify meningitis).
The absence of focal examination findings does not exclude the possibility of focal or
multifocal neurologic lesions as the cause of the delirium. In the absence of an obvious
cause for delirium, further testing including neuroimaging, lumbar puncture, and EEG is
indicated.
Clinical instruments — The Confusion Assessment Method (CAM) is a simple tool that
can be used by clinicians to integrate their observations and identify when delirium is the
most probable diagnosis (table 4). In medical and surgical settings, the CAM has a
sensitivity of 94 to 100 percent and a specificity of 90 to 95 percent [26]. The CAM has
become a standard screening device in clinical studies of delirium, conducted across
multiple settings including emergency rooms and long-term care [27]. It takes five minutes
to administer and may be particularly helpful when incorporated into the routine bedside
assessment. A review of 11 bedside instruments used to identify the presence of delirium
in adults concluded that the best evidence supported the use of the CAM as the best, and
the Mini Mental State Exam as the least accurate test [28].
The CAM-ICU instrument has been developed and validated for identification of delirium in
the intensive care unit (ICU) [29-31]. In mechanically ventilated patients who are unable to
communicate verbally, the instrument considers observed behaviors and nonverbal
responses to simple questions, as well as visual and auditory recognition tasks (table 4).
Another instrument, the Intensive Care Delirium Checklist for Screening (ICDSC), has also
been validated in the diagnosis of delirium in the ICU setting and had high agreement
rates with the CAM-ICU in one study [32,33].
A cost-effective work-up for delirium focuses upon these most likely possibilities.
(See "Delirium and acute confusional states: Prevention, treatment, and prognosis".)
Medication review — Drug toxicity accounts for approximately 30 percent of all cases of
delirium [16]. Thus, the most important initial step is a medication review. The most
common offenders are listed in the Table (table 2) [16]. Clinicians should be careful not to
neglect over-the-counter agents, drugs prescribed by other physicians, or drugs belonging
to other household members. A simple but high-yield diagnostic procedure is to ask a
family member to clean out the medicine cabinet and bring the contents for review.
●Frontal — Patients with bifrontal lesions (eg, from tumor or trauma) often show
akinetic mutism, lack of spontaneity, lack of judgment, problems with recent or
working memory, blunted or labile emotional responses, and incontinence. These
features may closely resemble delirium. Neuroimaging may be required to
differentiate frontal lesions from delirium and confusional states in difficult cases.
Confusion or delirium due to acute or subacute brain lesions, such as stroke or multifocal
white matter inflammation, may occur without focal deficits on examination [36-39]. One
retrospective study of 127 consecutive neurology consultations for isolated acute mental
status change found stroke as the cause in nine patients (7 percent) [37]. Of these, three
patients (2.7 percent) with stroke had no focal neurologic findings, and one of these was a
subarachnoid hemorrhage. Risk factors for delirium in the setting of stroke include pre-
existing cognitive impairment, infection, right hemispheric stroke, anterior circulation large
vessel stroke, and greater stroke severity [39].
Confusion or delirium may follow head injury even in the absence of focal neurologic
deficits.
Dementia — Dementia may sometimes be confused with delirium or confusion and vice-
versa. However, characteristic differences in progression and cognitive features usually
distinguish these disorders.
●Dementia with Lewy bodies (DLB) is similar to Alzheimer disease but can be more
easily confused with delirium, because fluctuations and visual hallucinations are
common and prominent. (See "Clinical features and diagnosis of dementia with Lewy
bodies".)
Mania can be confused with hyperactive delirium with agitation, delusions, and psychotic
behavior. However, mania is usually associated with a history of previous episodes of
mania or depression. In schizophrenia, the delusions are usually highly systematized, the
history is longer, and the sensorium is otherwise clear.
DIAGNOSTIC TESTS
Laboratory tests — A number of laboratory tests may be considered in the patient with
delirium. However, the desire for diagnostic completeness can increase costs and possibly
delay the prompt treatment of more obvious disorders. Targeted testing is appropriate in
most instances.
●Toxic screen of blood and urine should be obtained from patients with acute delirium
or confusion when a cause is not immediately obvious. Again, clinicians must be
aware that some common drugs (eg, risperidone) are not assessed in routine
laboratory screens. Therefore, overdose of these drugs cannot be excluded by
negative results from a toxic screen.
●Further testing, such as liver function tests, should be based upon the history and
clinical examination. A report of slow cognitive decline over several months, for
example, will increase the importance of evaluating thyroid function and vitamin B12
levels.
The need for imaging should be guided by patient history and findings on neurologic
examination. Neuroimaging may not be necessary if a patient with acute delirium meets
the following conditions: the initial clinical evaluation discloses an obvious treatable
medical illness or problem, there is no evidence of trauma, no new focal neurologic signs
are present, and the patient is arousable and able to follow simple commands. However,
neuroimaging should be reconsidered if the patient doesn't improve as expected.
Neuroimaging may still be required if the delirium does not improve despite appropriate
treatment of the underlying medical problem. In addition, imaging should be considered if
the neurologic examination is confounded by diminished patient responsiveness or
cooperation.
There have been no well-designed prospective studies to assess the yield of neuroimaging
in patients with delirium. Abnormalities on head CT are commonly seen, but they usually
represent chronic conditions that predispose to delirium rather than acute, treatable
causes [42]. Examples of retrospective studies include:
●A retrospective study of 294 patients with acute confusion found revealed abnormal
CTs in 14 percent overall [43]. However, only 4 percent of patients without focal signs
had abnormal CT; the lowest yield of CT (2 percent) was in patients with premorbid
dementia and no focal neurologic signs.
●In a review of CT scans performed in 123 medical intensive care unit patients, new
CT findings were present in 26, leading to a change in diagnosis in 11 and a new
treatment plan in 6 [36]. Most studies were performed for an indication of "altered
mental status" and findings included cerebral infarction in 13, intracranial hemorrhage
in 2, and tumor in 3.
●In another review of 279 head CT scans performed in the emergency department in
patients older than 70 years, 42 (15 percent) revealed an acute condition [38]. Of
these, 40 were found in patients with either significantly impaired consciousness (eg,
unable to open eyes, speak, or follow simple commands) and/or new focal neurologic
findings.
Fewer data exist for MRI evaluation of patients with delirium. However, MRI is more
sensitive than head CT for acute stroke, posterior fossa lesions, and white matter lesions,
however, such findings may not influence immediate treatment course in critically ill
patients [44]. In patients with delirium of unknown cause and negative head CT, MRI may
be useful to exclude acute or subacute stroke and multifocal inflammatory lesions (eg, as
seen in reversible posterior leukoencephalopathy and acute disseminated
encephalomyelitis).
Lumbar puncture — Older patients with bacterial meningitis are more likely to present
with delirium rather than the classic triad of fever, headache, and meningismus. Bacterial
meningitis is an uncommon disorder, and routine cerebrospinal fluid (CSF) evaluation may
not be necessary in all febrile or septic appearing older patients with delirium as long as
other infectious foci are obvious. However, CSF analysis may be the only diagnostic tool
that will identify bacterial or aseptic meningitis and encephalitis.
In a retrospective study of 81 elderly patients who were admitted to the hospital for the
evaluation of fever and mental status changes, CSF cultures were negative for bacterial
growth in 80 of 81 patients [45]. However, one case of bacterial meningitis and one case of
aseptic meningitis were diagnosed by CSF findings. In a retrospective review of 232
lumbar punctures performed in hospitalized patients for the indication of altered mental
status, 11 percent were abnormal; the yield was highest in those suspected of community-
acquired meningitis [46].
Lumbar puncture is mandatory when the cause of delirium is not obvious. Clinicians
should also have a low threshold for obtaining CSF in febrile patients with delirium, even
when alternate explanatory conditions for delirium are present or suspected.
Neuroimaging should be obtained prior to lumbar puncture in patients with coma, focal
signs, papilledema, or suspicion of increased intracranial pressure because of the very low
but real risk of precipitating transtentorial herniation. If lumbar puncture is delayed and the
suspicion of bacterial meningitis is high, empiric antibiotic treatment should be considered.
(See "Lumbar puncture: Technique, indications, contraindications, and complications in
adults", section on 'Complications' and "Clinical features and diagnosis of acute bacterial
meningitis in adults".)
EEG testing — Electroencephalography (EEG) is useful in patients with altered
consciousness in order to [47,48]:
Nonconvulsive seizures lack motor manifestations or convulsions, but they may impair
consciousness. Nonconvulsive status epilepticus may cause continuous or fluctuating
impairment of consciousness, and EEG is the only method that can make the diagnosis.
One report evaluated 198 EEGs performed for the indication of altered consciousness
without convulsions and found definite or probable nonconvulsive status epilepticus in 74
(37 percent) [49]. In another study, continuous EEG monitoring was performed for
unexplained decrease in consciousness or detection of subclinical seizures in 570 critically
ill patients [50]. Seizures were detected in 110 patients (19 percent), and the seizures
were exclusively nonconvulsive in 92 percent of these individuals. Coma patients
frequently required greater than 24 hours of monitoring to detect the first electrographic
seizure.
Metabolic encephalopathies may show diffuse bilateral slowing of background rhythm and
moderate or high wave amplitude. Triphasic waves are associated with hepatic
encephalopathy but can be seen in other severe metabolic disturbances including uremic
and septic encephalopathy [51,52]. Viral encephalitis is typically associated with diffuse
background slowing and occasional epileptiform activity or electrographic seizures. Herpes
simplex encephalitis may be associated with high amplitude periodic complexes in the
temporal lobe leads.
EEG evaluation should be obtained for any patient with altered consciousness of unknown
etiology [40]. Patients with a remote or recent history of head trauma, stroke, seizures, or
focal brain lesions may be at higher risk of convulsive and nonconvulsive seizures.
However, neither clinical signs nor prior history predicted which of the 198 EEGs showed
nonconvulsive status in the study cited above [49].
●Beyond the Basics topic (see "Patient education: Delirium (Beyond the Basics)")
●Nearly 30 percent of older medical patients experience delirium at some time during
hospitalization. The incidence is higher in those with advanced age and pre-existing
brain disease (See 'Epidemiology' above.)
●The past medical history, a review of medications, and a physical examination may
provide clues as to the underlying etiology (See 'History' above and 'General
examination' above.)