Delirium

Abstract

Delirium or acute confusional state is characterized by a fluctuating level of consciousness with impairment of attention, perception, and thinking. Four primary features include disturbance of consciousness, disturbance of cognition, limited course, and external causation. In the initial assessment of patients, one should provide reorientation and reassurance. If the patient is agitated, physical restraints should be avoided as much as possible. In obtaining the history, details about psychotropic medications and medical conditions especially renal and liver impairment are important. Alcohol and drug use should be ascertained. The examination should evaluate for signs of meningism, neurological focality, and cutaneous manifestations of infectious etiologies. Pupillary findings may be useful in implicating drug/toxic effects. Initial labs should always include urinalysis and if a fever is present, urine blood cultures and sensitivities. Further work-up may involve head imaging, lumbar puncture, and EEG. Specific treatment depends on the underlying cause and often involves cessation of offending medications, treatment of underlying infections, or metabolic/electrolyte disturbances. Active orientation strategies may be helpful especially in patients with “sundowning.” In the elderly, delirium is associated with increased mortality of up to 40 % in 1 year after hospital discharge.