Delirium primer

Delirium is a sudden-onset and fluctuating course consisting of confusion, altered consciousness, distractibility, and behavioral change due to an underlying medical condition that causes altered brain functioning. It is usually reversible but carries a high mortality rate as patients are often experiencing organ system failure at some level

Delirium is rarely caused by psychiatric illness, but cases of “manic delirium” are reported in severe cases of bipolar mania

Typical causes include

• – Alcohol or sedative drug withdrawal

• – Drug intoxication or withdrawal

• – Electrolyte or other body chemical disturbances

• – Infections such as urinary tract infections or pneumonia (more likely in people who already have brain damage from stroke or dementia)

• – Poisons

• – Surgery

Psychiatric symptoms include

• – Disorganized thinking

  • Speech that does not make sense (incoherent)

  • Inability to stop speech patterns or behaviors

• – Emotional or personality changes

  • Anger

  • Agitation

  • Anxiety

  • Apathy

  • Depression

  • Euphoria

  • Irritability

Common tests used to determine the cause of delirium include

• – Blood ammonia levels

• – Blood chemistry (comprehensive metabolic panel)

• – Blood gas analysis

• – Chest X-ray

• – CSF analysis

• – Creatine kinase level in the blood

• – Drug, alcohol levels (toxicology screen)

• – EEG

• – Head CT scan

• – Head MRI scan

• – Liver function tests

• – Mental status test

• – Serum magnesium

• – Thyroid function tests

• – Urinalysis

• – Vitamin B1 and B12 levels

Key treatment variables include

• – Ideally, patient should be located in a pleasant, comfortable, non-threatening, physically safe environment

• – Stopping or changing medications that worsen confusion, or that are not necessary, may improve mental function significantly

• – Medications that may worsen confusion include

  • Alcohol

  • Analgesics, especially opioids such as codeine, hydrocodone, morphine, or oxycodone

  • Anticholinergics

  • CNS depressants

  • Cimetidine

  • Illicit drugs

• – Disorders that contribute to confusion should be treated. These may include

  • Anemia

  • Decreased oxygen (hypoxia)

  • Heart failure

  • High carbon dioxide levels (hypercapnia)

  • Infections

  • Kidney failure

  • Liver failure

  • Nutritional disorders

  • Psychiatric conditions (such as depression)

  • Thyroid disorders

Avoid sensory deprivation. Some patients with delirium may benefit from using hearing aids, glasses, etc., and frequent orientation

Posttest self-assessment question and answer

What are common causes of acute-onset psychosis?

A. Stimulant intoxication

B. Medically induced delirium

C. Alcohol or BZ withdrawal

D. Paranoid schizophrenia

E. A and B

F. A, B, and C

G. All of the above

Answer: F

This case emphasized the acute psychotic onset of a medical delirium, but drug intoxication and withdrawal may produce a similar picture. Schizophrenia usually is accompanied by a prodrome and gradually escalating psychotic symptoms that occur over weeks to months, and therefore this option is incorrect.

References

1.Bressi C, Porcellana M, Marinaccio PM, Nocito EP, Magri L. Short-term psychodynamic psychotherapy versus treatment as usual for depressive and anxiety disorders: a randomized clinical trial of efficacy. J Nerv Ment Dis 2010; 198:647–52.

2.Driessen E, Cuijpers P, de Maat SC, et al. The efficacy of short-term psychodynamic psychotherapy for depression: a meta-analysis. Clin Psychol Rev 2010; 30:25–36.

3.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Revised, 4th edn. Washington, DC: American Psychiatric Association Press, 2000.

4.Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th edn. Philadelphia, PA: Lippincott Williams & Wilkins, 2007.

5.American Psychiatric Association. Practice Guideline for the Treatment of Patients with Delirium. Washington, DC: American Psychiatric Publishing Inc., 1999.

6.Inouye SK. Delirium and other mental status problems in the older patient. In: Goldman L, Ausiello D, eds. Cecil Medicine, 23rd edn. Philadelphia, PA: Saunders Elsevier, 2007.

7.Schwartz TL, Masand PS. The role of atypical antipsychotics in the treatment of delirium. Psychosomatics 2002; 43:171–4.

8.Schwartz TL, Dewan MJ, Lamparella V, Armenta W. Sustained manic delirium. J Pharm Technol 2000; 16:147–50.

Patient file

The Case:

The man with a little bit of everything

The Question:

What to do when a patient does not meet full diagnostic criteria for anything

The Dilemma:

Categorical versus symptomatic treatment