Delirium

Delirium is a serious disturbance in mental abilities that results in confused thinking and reduced awareness of the environment. The start of delirium is usually rapid — within hours or a few days.

Delirium can often be traced to one or more contributing factors, such as a severe or chronic illness, changes in metabolic balance (such as low sodium), medication, infection, surgery, or alcohol or drug intoxication or withdrawal.

Because symptoms of delirium and dementia can be similar, input from a family member or caregiver may be important for a doctor to make an accurate diagnosis.

Symptoms

Signs and symptoms of delirium usually begin over a few hours or a few days. They often fluctuate throughout the day, and there may be periods of no symptoms. Symptoms tend to be worse during the night when it's dark and things look less familiar. Primary signs and symptoms include those below.

Reduced awareness of the environment

This may result in:

• An inability to stay focused on a topic or to switch topics
• Getting stuck on an idea rather than responding to questions or conversation
• Being easily distracted by unimportant things
• Being withdrawn, with little or no activity or little response to the environment

Poor thinking skills (cognitive impairment)

This may appear as:

• Poor memory, particularly of recent events
• Disorientation — for example, not knowing where you are or who you are
• Difficulty speaking or recalling words
• Rambling or nonsense speech
• Trouble understanding speech
• Difficulty reading or writing

Behavior changes

These may include:

• Seeing things that don't exist (hallucinations)
• Restlessness, agitation or combative behavior
• Calling out, moaning or making other sounds
• Being quiet and withdrawn — especially in older adults
• Slowed movement or lethargy
• Disturbed sleep habits
• Reversal of night-day sleep-wake cycle

Emotional disturbances

These may appear as:

• Anxiety, fear or paranoia
• Depression
• Irritability or anger
• A sense of feeling elated (euphoria)
• Apathy
• Rapid and unpredictable mood shifts
• Personality changes

Types of delirium

Experts have identified three types of delirium:

• Hyperactive delirium. Probably the most easily recognized type, this may include restlessness (for example, pacing), agitation, rapid mood changes or hallucinations, and refusal to cooperate with care.
• Hypoactive delirium. This may include inactivity or reduced motor activity, sluggishness, abnormal drowsiness, or seeming to be in a daze.
• Mixed delirium. This includes both hyperactive and hypoactive signs and symptoms. The person may quickly switch back and forth from hyperactive to hypoactive states.

Delirium and dementia

Dementia and delirium may be particularly difficult to distinguish, and a person may have both. In fact, delirium frequently occurs in people with dementia. But having episodes of delirium does not always mean a person has dementia. So a dementia assessment should not be done during a delirium episode because the results could be misleading.

Dementia is the progressive decline of memory and other thinking skills due to the gradual dysfunction and loss of brain cells. The most common cause of dementia is Alzheimer's disease.

Some differences between the symptoms of delirium and dementia include:

• Onset. The onset of delirium occurs within a short time, while dementia usually begins with relatively minor symptoms that gradually worsen over time.
• Attention. The ability to stay focused or maintain attention is significantly impaired with delirium. A person in the early stages of dementia remains generally alert.
• Fluctuation. The appearance of delirium symptoms can fluctuate significantly and frequently throughout the day. While people with dementia have better and worse times of day, their memory and thinking skills stay at a fairly constant level during the course of a day.

When to see a doctor

If a relative, friend or someone in your care shows any signs or symptoms of delirium, see a doctor. Your input about the person's symptoms, typical thinking and everyday abilities will be important for a proper diagnosis and for finding the underlying cause.

If you notice signs and symptoms of delirium in a person in a hospital or nursing home, report your concerns to the nursing staff or doctor rather than assuming that those problems have been observed. Older people recovering in the hospital or living in a long-term care facility are particularly at risk of delirium.

Causes

Delirium occurs when the normal sending and receiving of signals in the brain become impaired. This impairment is most likely caused by a combination of factors that make the brain vulnerable and trigger a malfunction in brain activity.

Delirium may have a single cause or more than one cause, such as a combination of a medical condition and drug toxicity. Sometimes no cause can be identified. Possible causes include:

• Certain medications or drug toxicity
• Alcohol or drug intoxication or withdrawal
• A medical condition, such as a stroke, heart attack, worsening lung or liver disease, or an injury from a fall
• Metabolic imbalances, such as low sodium or low calcium
• Severe, chronic or terminal illness
• Fever and acute infection, particularly in children
• Urinary tract infection, pneumonia or the flu, especially in older adults
• Exposure to a toxin, such as carbon monoxide, cyanide or other poisons
• Malnutrition or dehydration
• Sleep deprivation or severe emotional distress
• Pain
• Surgery or other medical procedures that include anesthesia

Several medications or combinations of drugs can trigger delirium, including some types of:

• Pain drugs
• Sleep medications
• Medications for mood disorders, such as anxiety and depression
• Allergy medications (antihistamines)
• Asthma medications
• Steroid medicines called corticosteroids
• Parkinson's disease drugs
• Drugs for treating spasms or convulsions

Risk factors

Any condition that results in a hospital stay, especially in intensive care or after surgery, increases the risk of delirium, as does being a resident in a nursing home. Delirium is more common in older adults.

Examples of other conditions that increase the risk of delirium include:

• Brain disorders such as dementia, stroke or Parkinson's disease
• Previous delirium episodes
• Visual or hearing impairment
• The presence of multiple medical problems

Complications

Delirium may last only a few hours or as long as several weeks or months. If issues contributing to delirium are addressed, the recovery time is often shorter.

The degree of recovery depends to some extent on the health and mental status before the onset of delirium. People with dementia, for example, may experience a significant overall decline in memory and thinking skills. People in better health are more likely to fully recover.

People with other serious, chronic or terminal illnesses may not regain the levels of thinking skills or functioning that they had before the onset of delirium. Delirium in seriously ill people is also more likely to lead to:

• General decline in health
• Poor recovery from surgery
• Need for institutional care
• Increased risk of death

Prevention

The most successful approach to preventing delirium is to target risk factors that might trigger an episode. Hospital environments present a special challenge — frequent room changes, invasive procedures, loud noises, poor lighting, and lack of natural light and sleep can worsen confusion.

Evidence indicates that certain strategies — promoting good sleep habits, helping the person remain calm and well-oriented, and helping prevent medical problems or other complications — can help prevent or reduce the severity of delirium.

Diagnosis

A doctor can diagnose delirium on the basis of medical history, tests to assess mental status and the identification of possible contributing factors. An examination may include:

• Mental status assessment. A doctor starts by assessing awareness, attention and thinking. This may be done informally through conversation, or with tests or screenings that assess mental state, confusion, perception and memory. Additional information from family members or caregivers can be helpful.
• Physical and neurological exams. The doctor performs a physical exam, checking for signs of health problems or underlying disease. A neurological exam — checking vision, balance, coordination and reflexes — can help determine if a stroke or another neurological disease is causing the delirium.
• Other tests. The doctor may order blood, urine and other diagnostic tests. Brain-imaging tests may be used when a diagnosis can't be made with other available information.

Treatment

The first goal of treatment for delirium is to address any underlying causes or triggers — for example, by stopping use of a particular medication, addressing metabolic imbalances or treating an infection. Treatment then focuses on creating the best environment for healing the body and calming the brain.

Supportive care

Supportive care aims to prevent complications by:

• Protecting the airway
• Providing fluids and nutrition
• Assisting with movement
• Treating pain
• Addressing incontinence
• Avoiding use of physical restraints and bladder tubes
• Avoiding changes in surroundings and caregivers when possible
• Encouraging the involvement of family members or familiar people

Medications

If you're a family member or caregiver of someone who experiences delirium, talk with the doctor about avoiding or minimizing the use of drugs that may trigger delirium. Certain medications may be needed to control pain that's causing delirium.

Other types of medications may help calm a person who has severe agitation or confusion or who misinterprets the environment in a way that leads to severe paranoia, fear or hallucinations. These medications may be needed when certain behaviors:

• Prevent the performance of a medical exam or treatment
• Endanger the person or threaten the safety of others
• Don't lessen with nondrug treatments

These medications are usually reduced in dose or discontinued when the delirium resolves.

Coping and support

If you're a relative or caregiver of someone at risk of or recovering from delirium, you can take steps to help improve the person's health, prevent a recurrence and manage responsibilities.

Promote good sleep habits

To promote good sleep habits:

• Provide a calm, quiet environment
• Keep inside lighting appropriate for the time of day
• Plan for uninterrupted periods of sleep at night
• Help the person keep a regular daytime schedule
• Encourage self-care and activity during the day

Promote calmness and orientation

To help the person remain calm and well-oriented:

• Provide a clock and calendar and refer to them regularly throughout the day
• Communicate simply about any change in activity, such as time for lunch or time for bed
• Keep familiar and favorite objects and pictures around, but avoid a cluttered environment
• Approach the person calmly
• Identify yourself or other people regularly
• Avoid arguments
• Use comfort measures, such as reassuring touch, when appropriate
• Minimize noise levels and other distractions
• Provide and maintain eyeglasses and hearing aids

Prevent complicating problems

Help prevent medical problems by:

• Giving the person the proper medication on a regular schedule
• Providing plenty of fluids and a healthy diet
• Encouraging regular physical activity
• Getting prompt treatment for potential problems, such as infections or metabolic imbalances

Caring for the caregiver

Providing regular care for a person with delirium can be scary and exhausting. Take care of yourself, too.

• Consider joining a support group for caregivers.
• Learn more about the condition.
• Ask for educational materials or other resources from a health care provider, nonprofit organizations, community health services or government agencies.
• Share caregiving with family and friends who are familiar to the person so you get a break.

Examples of organizations that may provide helpful information include the Caregiver Action Network and the National Institute on Aging.

Preparing for an appointment

If you're the relative or primary caregiver of a person with delirium, you'll likely play a role in making an appointment or providing information to the doctor. Here's some information to help you get ready for the appointment and know what to expect from the doctor.

What you can do

Before the appointment, make a list of:

• All medications, including all prescriptions, over-the-counter medications and supplements the person takes, and the dosages — noting any recent medication changes
• Names and contact information of any health care providers, therapists or other clinicians who provide care for the person
• The symptoms and when they started, describing all signs and symptoms and minor changes in behaviors that preceded the delirium symptoms, such as pain, fever or coughing
• Questions you want to ask the doctor

What to expect from the doctor

The doctor is likely to ask a number of questions about the person with delirium. These may include:

• What are the symptoms and when did they begin?
• Is there or was there a recent fever, cough, urinary tract infection or sign of pain?
• Is there or was there a recent fever, cough or urinary tract infection?
• Was there a recent head injury or other trauma?
• What were the person's memory and other thinking skills like before the symptoms started?
• How well did the person perform everyday activities before the onset of symptoms?
• Can he or she usually function independently?
• What other medical conditions have been diagnosed?
• Are prescription medications taken as directed? When did the person take the most recent dose of each?
• Are there any new medications?
• Do you know if the person recently used drugs or alcohol? Does the person have a history of alcohol or drug misuse? Is there any change in the pattern of use, such as increasing or stopping use?
• Has the person recently appeared depressed, extremely sad or withdrawn?
• Has the person indicated that he or she does not feel safe?
• Are there any signs of paranoia?
• Has the person seen or heard things that no one else does?
• Are there any new physical symptoms — for example, chest or abdominal pain?

The doctor will ask additional questions based on your responses and the person's symptoms and needs. Preparing and anticipating questions will help you make the most of your appointment time.

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