What Is Delirium?

Delirium is the commonest cause of sudden onset confusion in the elderly. It is a reaction of the mind or brain to changes in physical condition and is not related to a primary brain disorder. Apart from the confusion the patient is often physically and medically very unwell. Delirium in itself is an independent predictor of death in in-hospital patients and carries a mortality risk of 10%. Therefore, early recognition and treatment of this condition is of prime importance.

What Are The Symptoms Of Delirium?

The diagnosis of delirium is clinical. The following features may be present:

  • Usually sudden presentation over hours to days.
  • Fluctuating course.
  • Consciousness is clouded/impaired cognition/disorientation.
  • Poor concentration.
  • Memory deficits – predominantly poor short-term memory.
  • Abnormalities of sleep-wake cycle, including sleeping in the day.
  • Abnormalities of perception – e.g. hallucinations or illusions.
  • Agitation.
  • Emotional lability.
  • Psychotic ideas are common but of short duration and of simple content.

Neurological signs – e.g. unsteady gait and tremor.

What Are The Causes Of Delirium?

Usually there is a precipitating medical illness for delirium. The common causes include:

  • Infection (chest or urine)
  • Dehydration
  • Pain
  • Fall
  • Fracture
  • New Medication
  • Surgery
  • ICU Admission
  • Constipation
  • Simply Change of Residence

The list is not exhaustive and literally any medical illness can precipitate delirium in the elderly.

Diagnosis For Delirium

The symptoms of delirium are often confused with Dementia as they are similar. Delirium is also more common in patients with dementia. However important differences exist between these conditions.

  • Delirium typically is of sudden onset over hours to days and is fast progressive. Dementia on the other hand is a slow process where the confusion and memory impairment start and progress over months to years.
  • Delirium describes a fluctuating course of confusion, often interspersed with periods of complete lucidity. Dementia on the other hand is a progressively worsening condition


Assessment Of Delirium

This should be guided by the clinical presentation and the main aim is to identify the underlying cause of the delirium. Typical investigations that can be performed include:

  • Full history, including collateral history and cognition testing – eg, mini mental state examination.
  • Full clinical examination.
  • Blood tests looking to identify infection or dehydration.
  • Urine test for infection.
  • Medication review.
  • ECG.
  • CXR and possibly abdominal X-ray, if indicated.
  • CT scan of the brain.


Management Of Delirium

  • The most important step in treatment of delirium is its recognition.
  • Recognition and treatment of the underlying medical illness is of primary importance. Resolution of the primary medical problem will result in spontaneous resolution of the delirium over time.
  • Supportive measures like good hydration and avoiding constipation helps. Regular orientation of the patient as to where they are, especially during the lucid intervals help.
  • Use of medication towards sedating the patient when they are confused should be avoided. Antipsychotics and sedative medication use should be restricted to extreme circumstances.
  • If delirium is drug induced stop the offending agent and provide supportive measures for some time to allow the delirium to resolve.

Dr. Dwaipayan Sen (FRCP(Glasgow) MRCP Geriatrics)

Consultant Stroke Physician, UK

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