Patient education: Delirium (Beyond the Basics)

DELIRIUM OVERVIEW — Delirium is a sudden and severe change in brain function that causes a person to appear confused or disoriented, or to have difficulties maintaining focus, thinking clearly, and remembering recent events, typically with a fluctuating course. Delirium can be triggered by a serious medical illness such as an infection, certain medications, and other causes, such as drug withdrawal or intoxication. Older patients, over 65 years, are at highest risk for developing delirium. People with previous brain disease or brain damage are also at risk. Some patients appear visibly agitated, while many others may be quietly confused.

Delirium is very common in patients admitted to intensive care units and acute care settings, but also occurs in other settings such as nursing homes and private homes, especially in high-risk patients. (See 'Risk factors' below.)

Delirium is distinct from dementia because it is usually temporary, resolving when the underlying cause is addressed promptly. Delirium also differs from the psychosis of psychiatric disease. However, these three conditions can sometimes appear similar.

The goal of treatment is to address the cause of delirium when possible and to keep the person safe as they recover from their illness.

DELIRIUM CAUSES — It is not clear why or how delirium develops. There are many potential causes, with the most common including infections, medications, and organ failure (such as severe lung or liver disease). In many cases, the underlying infection or condition is not a brain problem and affects brain function indirectly. As examples:

●Sepsis, a life-threatening illness caused by the body's response to severe infection, is often associated with changes in brain function even among people who are young and previously healthy.

●A urinary tract infection or dehydration can cause delirium in certain people.

●The time after surgery (called the postoperative period) is a common time for delirium to develop, especially in older people. This may be related to pain or the use of anesthesia or pain medications.

●Patients with respiratory infections (eg, coronavirus disease 2019 [COVID-19]) may experience delirium during the acute phase of their illness, and some may also experience persistent memory and attention deficits ("brain fog") for months thereafter.

●Sudden withdrawal of a regular prescribed or nonprescribed drug or cessation of regular alcohol use can cause delirium.

However, in other cases, delirium can be due to temporary dysfunction arising in the brain, such as an epileptic seizure, a threatened stroke (transient ischemic attack [TIA]), or a concussion.

Risk factors — Certain underlying conditions increase the risk of delirium:

●Advanced age

●Underlying brain diseases such as dementia, stroke, or Parkinson disease, particularly when there are current problems with memory

●Use of multiple medications (particularly psychiatric drugs and sedatives), or multiple medical problems

●Frailty, malnutrition, immobility

●Advanced cancer

●Undertreated pain (although excessive use of opioid pain medication for pain control can also impair brain function)

●Immobilization, including physical restraints

●Use of bladder catheters

●Limb fractures

●Interventions, including diagnostic tests

●Poor eyesight or hearing

●Sleep deprivation

●Organ failure (eg, chronic lung disease; heart, kidney, or liver failure)

How common is delirium? — Nearly 30 percent of older patients experience delirium at some time during hospitalization; the incidence is higher in intensive care units. Among older patients who have had surgery, the risk of delirium varies from 10 to greater than 50 percent.

DELIRIUM SYMPTOMS — Delirium is not a disease, but rather a group of symptoms. The key features include:

●There are abnormal changes in the person's level of consciousness and thinking. The person may be sleepy or appear to be withdrawn and depressed (hypoactive delirium), or they may be agitated (hyperactive delirium). Some patients alternate between these states. The changes may be subtle initially. The mental status and level of consciousness commonly fluctuate throughout the day.

●The person often has difficulty maintaining focus. They may change the subject frequently in a conversation, have difficulty retaining new information, mention strange ideas, or be disoriented (in place or in time). Some patients have visual hallucinations. Tremor is common in withdrawal states and in some disturbances of organ function.

These changes develop over a short period of time (hours to days) and tend to become intermittently worse, especially in the afternoon and evening. This sudden change helps to differentiate delirium from dementia, which worsens slowly over months to years. (See "Patient education: Dementia (including Alzheimer disease) (Beyond the Basics)".)

Delirium also differs from the psychosis of psychiatric disease, in which orientation, concentration, and attention are usually less impaired. However, these features are not always reliable.

DELIRIUM EVALUATION — Delirium may be difficult to recognize because changes in behavior may be attributed to the person's age, history of dementia, or other mental disorders. In addition, the symptoms can come and go, such that a person has no or few symptoms early in the day but progressively worsens late in the day or in the evening.

If a caregiver or family member suspects that their relative has delirium, it is important that the person is evaluated promptly to identify the underlying cause and begin treatment if possible. Some life-threatening conditions can cause delirium, so it is important to be evaluated quickly. If the person is hospitalized, the evaluation may be done by the attending physician or team. If the person is at home, the patient should see their primary care provider or go to the emergency department. It is critical that clinicians evaluating a person with suspected delirium know the patient's full medical history and all current medications, both prescribed and over-the-counter. If the patient was recently seen at another hospital or clinical, electronic copies of the health record should be requested.

Laboratory testing — Blood and/or urine tests may be performed to determine the cause of the person's delirium. Delirium may be the first manifestation of a severe infection or sepsis, so additional tests to identify infection may be done. This may include testing for viral infection. A chest x-ray is often required to exclude pneumonia; urine testing may be performed to exclude urinary tract infection.

Brain imaging tests — If the cause of a person's delirium cannot be determined based upon the history, physical examination, and laboratory testing, a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan of the head may be recommended. This test can help to determine if an abnormal growth, bleeding, infection, or inflammation is present in the brain.

Lumbar puncture — During a lumbar puncture, or spinal tap, a clinician uses a needle to remove a sample of spinal fluid from the area around the spinal cord in the low back. Several tests are done on the fluid to determine if an infection (such as meningitis or encephalitis) could be causing delirium, and if so, which antibiotic treatment is best.

Lumbar puncture is not needed for most persons with delirium if other causes are evident. It may be performed if other tests are unable to determine the cause, or if there are other signs of central nervous system infection.

EEG testing — Electroencephalography (EEG) measures the electrical activity in the brain. It may be performed in a person with delirium to search for abnormal electrical activity that is commonly associated with seizures and epilepsy. It is not recommended for all people with delirium, but it may be performed if other tests are unable to determine the cause or if seizures are suspected.

DELIRIUM TREATMENT — There is no specific treatment for delirium. Instead, treatment focuses on several basic principles:

●Avoid factors known to cause or aggravate delirium, such as certain medications

●Identify and treat the underlying illness

●Provide supportive and restorative care

●Control dangerous and disruptive behaviors to avoid harm to the patient or others

In people with a first episode of delirium, the initial treatment is often provided in a hospital setting. This allows the health care provider to monitor the patient, begin treatment of the underlying problem, and develop a long-term care plan with the patient and/or family.

Supportive care — The goal of supportive care is to maintain the patient's health, prevent additional complications, and avoid those factors that can aggravate delirium. This includes:

●Making sure the person gets enough to eat and drink (or providing nutrition through an IV, if needed)

●Treating pain and avoiding discomfort, including avoiding constipation (see "Patient education: Constipation in adults (Beyond the Basics)")

●Minimizing the use of restraints and bladder catheters, which can be uncomfortable, particularly to confused patients

●Encouraging movement (getting out of bed in order to walk) with necessary assistance to avoid falls

●Having someone help during meals and having the person sit upright to minimize the risk of inhaling food, drinks, and/or saliva, which can lead to pneumonia

●Maintaining a regular night-day/sleep-wake cycle when possible and avoiding sleep deprivation

●Maintaining a reassuring and familiar environment with one or two visiting family members or familiar objects/pictures from home

●Avoiding overstimulation (eg, multiple visitors, loud noise), which can worsen delirium, but also avoiding understimulation (darkened room, complete silence)

●Making hearing aids and eyeglasses available at the hospital if the patient uses these at home

Managing behaviors — Some people with delirium have disruptive behaviors, potentially causing them to harm themselves or others. The person may say or do things that are obscene or offensive, but such behaviors do not reflect the person's true beliefs. The person may also be at risk for falling, wandering off, or inadvertently removing intravenous lines.

Sitter — Allowing a family member or other caregiver to stay with the patient at the bedside may help to manage the patient's behavior. This person can provide reassurance, answer questions, reorient the patient, and notify staff if the person needs assistance. In some cases, the hospital is able to provide a sitter if a family member is unavailable. However, a familiar and trusted family member or friend can provide additional reassurance to the patient.

Medications — Medications to control difficult behavior are only to be considered as a last resort, if the patient's agitation is so extreme as to be a potential source of harm. Some classes of drugs, especially sedatives such as lorazepam (Ativan) and diazepam (Valium), can build up in the bloodstream and cause the person to become more confused. Antipsychotic medications, such as haloperidol (Haldol), may be considered, but only in small doses and for short periods of time.

If used, these medications should be stopped frequently, with direction or approval by the physician, so that the patient can be reevaluated. Antipsychotic medications are not recommended for long-term treatment.

Restraints — The use of restraints (to tie a person to their bed or chair) is almost never appropriate, as restraints can increase agitation and create additional problems by preventing the person from moving around as needed. Preventing movement also potentially allows skin sores (called pressure ulcers) to develop from sitting or lying in the same position for long periods. The use of restraints has not been shown to prevent harmful falls among hospitalized patients.

However, in the rare situation where the patient is at high risk for harm and restraints are applied, hospital staff should monitor the patient at least every two hours, untying the restraints and changing the patient's position. The restraints should be removed as soon as possible.

DELIRIUM RECOVERY — Delirium has an enormous impact upon the health of older people. Patients with delirium may experience prolonged hospitalizations and a decreased ability to function independently, and are at high risk for requiring care in a long-term care facility (eg, nursing home). This may be the result of underlying conditions, such as mild dementia, that become unmasked or worsen as a result of the acute illness or medications that brought on the delirium. However, even patients with no prior history of brain disorders can require a long period of time to recover from delirium resulting from a severe illness.

Delirium can be frightening for the patient, as well as for the caregiver or family. Caregivers may feel exhausted and frustrated because of the time and other resources required to take care of a person with delirium.

Delirium can sometimes resolve within hours to days. In other cases, it takes weeks or months to fully resolve. For this reason, it is important for caregivers to discuss the patient's short- and long-term needs with a health care provider. Even patients that appear to have recovered from delirium may have trouble remembering medications and self-care instructions. Once the person is released from the hospital, additional assistance from family members or a home health nurse may be needed to assure a safe transition to home. In some cases, a rehabilitation or subacute care facility may be needed until the person has recovered and is able to care for themself. If the person is unlikely to be able to care for themself again, then ongoing formal home-based services or an assisted living facility or nursing home may be required.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Delirium (confusion) (The Basics)
Patient education: Disseminated intravascular coagulation (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Dementia (including Alzheimer disease) (Beyond the Basics)
Patient education: Constipation in adults (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Acute toxic-metabolic encephalopathy in adults
Alcohol withdrawal: Ambulatory management
Anticholinergic poisoning
Approach to the patient with visual hallucinations
Arsenic exposure and chronic poisoning
Assessment and emergency management of the acutely agitated or violent adult
HIV-associated neurocognitive disorders: Epidemiology, clinical manifestations, and diagnosis
Diagnosis of delirium and confusional states
Patients with cancer: Overview of the clinical features and diagnosis of psychiatric disorders
Evaluation of abnormal behavior in the emergency department
Management of nonmotor symptoms in Parkinson disease
Management of psychiatric disorders in patients with cancer
Hip fracture in older adults: Epidemiology and medical management
Overview of the neuropsychiatric aspects of HIV infection and AIDS
Perioperative care of the surgical patient with neurologic disease
Delirium and acute confusional states: Prevention, treatment, and prognosis
Psychiatric illness in adults receiving maintenance dialysis
Wernicke encephalopathy

The following organizations also provide reliable health information.

●National Library of Medicine

     (www.medlineplus.gov/ency/article/000740.htm)

●National Cancer Institute

     (www.cancer.gov/about-cancer/treatment/side-effects/delirium)

●The Mayo Clinic

     (www.mayoclinic.com/health/delirium/DS01064)

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