Delirium

  • Joseph Francis

Abstract

The syndrome of delirium is one of the most common manifestations of acute illness or drug toxicity in older patients. Controversy surrounds the definition of delirium, because its manifestations are pleomorphic and its mechanisms poorly understood. The American Psychiatric Association, in its Diagnostic and Statistical Manual, fourth edition (DSM-IV), emphasizes four key features (Table 60.1). The first of these is disturbance of consciousness. Patients with delirium characteristically are less aware of their surroundings and have difficulty focusing, sustaining, or shifting attention. They become easily distracted and have difficulty following commands or maintaining a conversation. Accompanying delirium is an impairment of cognition and perception not attributable to prior or progressing dementia. This is manifested by memory problems, disorientation, misperceptions, hallucinations, and language problems (e.g., dysnomia, dysgraphia). The course of delirium is acute (defined as hours to days) and fluctuating (patients may be lucid during morning rounds yet combative or confused at night). Finally, delirium in an individual patient has one or more underlying medical etiologies.1

Keywords

Femoral Neck Fracture Neuroleptic Malignant Syndrome Acute Confusional State Delirious Patient Elderly Medical Patient 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. Washington, DC: American Psychiatric Association; 1994.Google Scholar
  2. 2.
    Liptzin B, Levkoff SE, Gottlieb GL, et al. Background papers for DSM-IV: Delirium. J Neuropsychiatr Clin Neurosci. 1993; 5: 154–160.Google Scholar
  3. 3.
    Gustafson Y, Brannstrom B, Norberg A, et al. Under-diagnosis and poor documentation of acute confusional states in elderly hip fracture patients. J Am Geriatr Soc. 1991; 39: 760–765.PubMedGoogle Scholar
  4. 4.
    Perez EL, Silverman M. Delirium: the often overlooked diagnosis. Int J Psychiatr Med. 1984; 14: 181–188.CrossRefGoogle Scholar
  5. 5.
    Francis J. Delirium in older patients. J Am Geriatr Soc. 1992; 40: 827–832.Google Scholar
  6. 6.
    Zubenko GS. Progression of illness in the differential diagnosis of primary dementia. Am J Psychiatry. 1990; 147: 435–438.PubMedGoogle Scholar
  7. 7.
    Bliwise DL. What is sundowning? J Am Geriatr Soc. 1994; 42: 1009–1011.PubMedGoogle Scholar
  8. 8.
    Romano J, Engel GL. Delirium: I. Electro-encephalographic data. Arch Neurol Psychiatry. 1944; 51: 356–377.CrossRefGoogle Scholar
  9. 9.
    Jacobson SA, Leuchter AF, Walter DO. Conventional and quantitative EEG in the diagnosis of delirium among the elderly. J Neurol Neurosurg Psychiatry. 1993; 56: 153–158.PubMedCrossRefGoogle Scholar
  10. 10.
    Martin M, Figiel G, Mattingly G, et al. ECT-induced interictal delirium in patients with a history of a CVA. J Geriatr Psychiatry Neurol. 1992; 5: 149–155.PubMedGoogle Scholar
  11. 11.
    Figiel GS, Hassen MA, Zorumski C. ECT-induced delirium in depressed patients with Parkinson’s disease. J Neuropsychiatr Clin Neurosci. 1991; 3: 405–411.Google Scholar
  12. 12.
    Trzepacz PT, Sclabassi RJ, van Thiel DH. Delirium: a subcortical phenomenon? J Neuropsychiatr. 1989; 1: 283–290.Google Scholar
  13. 13.
    Gibson GE, Blass JP, Huang HM, et al. The cellular basis of delirium and its relevance to age-related disorders including Alzheimer’s disease. Int Psycho geriatr. 1991; 3: 373–395.CrossRefGoogle Scholar
  14. 14.
    Tune LE, Bylsma FW. Benzodiazepine-induced and anticholinergic-induced delirium in the elderly. Int Psychogeriatr. 1991; 3: 397–408.PubMedCrossRefGoogle Scholar
  15. 15.
    Sunderland T, Tariot PN, Cohen RM, et al. Anticholinergic sensitivity in patients with dementia of the Alzheimer type and age-matched controls. Arch Gen Psychiatry. 1987; 44: 418–426.PubMedCrossRefGoogle Scholar
  16. 16.
    Ross CA. CNS arousal systems: possible role in delirium. Int Psychogeriatr. 1991; 3: 353–371.PubMedCrossRefGoogle Scholar
  17. 17.
    Renault PF, Hoofnagle JH, Park Y, et al. Psychiatric complications of long-term interferon alfa therapy. Arch Intern Med. 1987; 147: 1577–1580.PubMedCrossRefGoogle Scholar
  18. 18.
    Levkoff SE, Evans DA, Liptzin B, et al. Delirium: the occurrence and persistence of symptoms among elderly hospitalized patients. Arch Intern Med. 1992; 152: 334–340.PubMedCrossRefGoogle Scholar
  19. 19.
    Francis J, Martin D, Kapoor WN. A prospective study of delirium in hospitalized elderly. JAMA 1990;263:1097-1101 Google Scholar
  20. 20.
    Inouye SK, Viscoli CM, Horwitz RI, et al. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med. 1993; 119: 474–481.PubMedGoogle Scholar
  21. 21.
    Schor JD, Levkoff SE, Lipsitz LA, et al. Risk factors for delirium in hospitalized elderly. JAMA. 1992; 267: 827–831.PubMedCrossRefGoogle Scholar
  22. 22.
    Johnson JC, Gottlieb GL, Sullivan E, et al. Using DSM-III criteria to diagnose delirium in elderly general medical patients. J Gerontol. 1990; 45: M113–119.PubMedCrossRefGoogle Scholar
  23. 23.
    Pompei P, Foreman M, Rudberg MA, et al. Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc. 1994; 42: 809–815.PubMedGoogle Scholar
  24. 24.
    Marcantonio ER, Goldman L, Mangione CM, et al. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA. 1994; 271: 134–139.PubMedCrossRefGoogle Scholar
  25. 25.
    Smith LW, Dimsdale JE. Postcardiotomy delirium: conclusions after 25 years? Am J Psychiatry. 1989; 146: 452–458.PubMedGoogle Scholar
  26. 26.
    Gustafson Y, Berggren D, Brannstrom B, et al. Acute confusional states in elderly patients treated for femoral neck fracture./Am Geriatr Soc 1988; 36: 525–530.Google Scholar
  27. 27.
    Cole MG, Primeau FJ. Prognosis of delirium in elderly hospital patients. Can Med Assoc J. 1993; 149: 41–46.Google Scholar
  28. 28.
    Francis J, Kapoor WN. Prognosis after hospital discharge of older medical patients with delirium. J Am Geriatr Soc. 1992; 40: 601–606.PubMedGoogle Scholar
  29. 29.
    Murray AM, Levkoff SE, Wetle TT, et al. Acute delirium and functional decline in the hospitalized elderly patient./Gerontol 1993; 48: M181–186.Google Scholar
  30. 30.
    Drugs that cause psychiatric symptoms. Med Lett. 1993; 35: 65–70.Google Scholar
  31. 31.
    Kaiko RF, Foley KM, Grabinski PY, et al. Central nervous system excitatory effects of meperidine in cancer patients. Ann Neurol. 1983; 13: 180–185.PubMedCrossRefGoogle Scholar
  32. 32.
    Cantu TG, Korek JS. Central nervous system reactions to histamine-2 receptor blockers. Ann Intern Med. 1991; 114: 1027–1034.PubMedGoogle Scholar
  33. 33.
    Foy A, Drinkwater V, March S, Mearrick P. Confusion after admission to hospital in elderly patients using benzodiazepines. Br Med J. 1986; 293: 1072.CrossRefGoogle Scholar
  34. 34.
    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; 97: 278–288.PubMedCrossRefGoogle Scholar
  35. 35.
    Gustafson Y, Brannstrom B, Berggren D, et al. A geriatric-anesthesiologic program to reduce acute confusional states in elderly patients treated for femoral neck fractures. J Am Geriatr Soc. 1991; 39: 655–662.PubMedGoogle Scholar
  36. 36.
    Edmonds HL, Griffiths LK, van der Laken J, et al. Quantitative electroencephalographic monitoring during myocardial revascularization predicts postoperative disorientation and improves outcome. J Thorac Cardiovasc Surg. 1992; 103: 555–563.PubMedGoogle Scholar
  37. 37.
    Williams MA, Campbell EB, Raynor WJ, et al. Reducing acute confusional states in elderly patients with hip fractures. Res Nurs Health. 1985; 8: 329–337.PubMedCrossRefGoogle Scholar
  38. 38.
    Benbadis SR, Sila CA, Cristea RL. Mental status changes and stroke. J Gen Intern Med. 1994; 9: 485–487.PubMedCrossRefGoogle Scholar
  39. 39.
    Warshaw G, Tanzer F. The effectiveness of lumbar puncture in the evaluation of delirium and fever in the hospitalized elderly. Arch Fam Med. 1993; 2: 293–297.PubMedCrossRefGoogle Scholar
  40. 40.
    Goldberg RJ. The use of constant observation in general hospitals. Int J Psychiatr Med. 1989; 19: 193–201.CrossRefGoogle Scholar
  41. 41.
    Smilkstein MJ. As the pendulum swings: the saga of physo-stigmine (editorial). J Emerg Med. 1991; 9: 275–277.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 1997

Authors and Affiliations

  • Joseph Francis

There are no affiliations available

Personalised recommendations