Delirium

Case Study

Patient: James, 72-year-old Male

Presenting Complaint:

James was brought to the hospital by his daughter due to sudden confusion, restlessness, and agitation over the past 24 hours.

History of Presenting Illness:

• Previously alert and independent, but became disoriented and unable to recognize family.
• Fluctuating consciousness—sometimes lucid, sometimes drowsy and confused.
• Visual hallucinations—reports seeing “people in the room” who aren’t there.
• Recent hospital admission for pneumonia—currently on antibiotics.
• No history of dementia or psychiatric illness.

Examination Findings:

• Neurological: Impaired attention, disoriented to time and place.
• Vital Signs: Mild fever, tachycardia.
• Cognitive Assessment: Unable to maintain focus during questions.
• Gait: Restless, trying to get out of bed without assistance.

Diagnosis:

James meets the criteria for delirium, likely due to infection (pneumonia) and recent hospitalization.

Management:

1. Identify & Treat Underlying Cause – Investigate infection, dehydration, metabolic imbalance.
2. Supportive Care – Reorientation techniques, calm environment, family involvement.
3. Medications (If Severe Agitation) – Haloperidol (low dose) only if necessary.
4. Regular Monitoring – Check hydration, medications, and cognitive fluctuations.

James gradually improved with IV fluids, infection treatment, and a calm hospital environment.

Definition

• Delirium is an acute and fluctuating disturbance in attention, awareness, and cognition caused by an underlying medical condition.
• Characterised by disorientation, inattention, altered consciousness, and hallucinations or delusions.

Medical emergency requiring prompt identification of the cause and management.

Causes & Risk Factors

Pathophysiology

• Imbalance in Neurotransmitters → Deficiency of Acetylcholine & Excess Dopamine.
• Neuroinflammation & Blood-Brain Barrier Dysfunction → Leads to Cognitive Impairment & Psychiatric Symptoms.
• Reduced Cerebral Perfusion or Oxygenation → Common in Critically Ill Patients.

Common Causes of Delirium (PINCH ME Mnemonic)

🔹 Delirium is a symptom of an underlying condition rather than a primary diagnosis.

Clinical Features

Core Symptoms of Delirium (ICD-10 Criteria)

Mnemonic for Delirium Symptoms: “A DACS”

Each letter represents a key feature of delirium:

• A → Acute & Fluctuating Course (Sudden onset, changes throughout the day)
• D → Disturbance in Attention & Awareness (Easily distracted, poor concentration, disorientation)
• A → Altered Consciousness (Hyperactive = Agitation, Hallucinations / Hypoactive = Lethargy, Withdrawal)
• C → Cognitive Impairment (Memory loss, language difficulties)
• S → Sleep-Wake Cycle Disturbance (Daytime drowsiness, night-time agitation)

Quick Recall Phrase:

“Delirium is A DACS (A Disoriented, Agitated, Confused State).”

This mnemonic should make it easy to recall the core symptoms of delirium! 🧠

🔹 Fluctuating confusion and inattention are key diagnostic features.

Types of Delirium

🔹 Hypoactive delirium is more common in older adults and is often underdiagnosed.

Referral Criteria (NICE Guidelines)

Urgent Referral (Medical Emergency – Requires Hospital Admission)

• New-Onset Acute Confusion in a Critically Ill or Elderly Patient.
• Delirium With Sepsis, Respiratory Distress, or Stroke Symptoms.
• Severe Agitation, Hallucinations, or Self-Harm Risk.
• Delirium in a Patient With Known Dementia or Cognitive Decline.

Routine Referral (If Symptoms Persist or Affect Functioning)

• Recurrent Delirium Episodes With No Clear Cause.
• Persistent Cognitive Impairment After Resolution of Acute Illness.

🔹 All suspected delirium cases should be investigated urgently to find and treat the underlying cause.

Diagnosis & Screening Tools

Clinical Diagnosis (Based on History & Examination)

Screening Tools for Delirium

Investigations to Identify the Underlying Cause

Differential Diagnosis

🔹 Dementia progresses slowly, while delirium has a sudden onset and fluctuating course.

Management (NICE Guidelines)

Identify & Treat the Underlying Cause !

• Sepsis → IV Antibiotics & Fluids.
• Electrolyte Imbalance → Correct Sodium, Potassium, Calcium.
• Hypoxia → Oxygen Therapy or Respiratory Support.
• Hypoglycaemia → IV Glucose.

Medications → Stop or Reduce Sedatives, Anticholinergics, Opioids.

Supportive Care & Environmental Management

🔹 Avoid benzodiazepines unless alcohol withdrawal is suspected.

Medications (For Severe Agitation Only)

• First-Line: Haloperidol (0.5 mg PO/IM) – Avoid in Parkinson’s Disease.
• Alternative (If Parkinson’s or Lewy Body Dementia): Lorazepam (0.5 mg PO/IM).
• Only Use Antipsychotics If Severe Distress or Risk to Self/Others.

🔹 Antipsychotics should be used sparingly and for the shortest duration possible.

Prognosis & Complications

Prognosis

Complications of Delirium

🔹 Patients who develop delirium are at increased risk of dementia in the future.

UKMLA Key Points

• Best first-line treatment for delirium: Identify & Treat Underlying Cause.
• Best distinguishing feature from dementia: Acute Onset & Fluctuating Course.
• When to refer urgently: Severe agitation, respiratory distress, sepsis.
• Best long-term prevention: Reduce Polypharmacy, Improve Sleep Hygiene.