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Delirium
Michele Ritter, M.D.
Argy February, 2007
Delirium vs. Dementia
 Dementia:
Slow evolution of multiple cognitive deficits
 Delirium
 DSM-IV:

 Disturbance of consciousness (ie, reduced clarity of awareness of
the environment) with reduced ability to focus, sustain or shift
attention
 A change in cognition (such as memory deficity, disorientation,
language disturbance) or the development of a perceptual
disturbance that is not better accounted for my a pre-existing or
evolving dementia
 The disturbance develops over a short period of time (usually
hours to days) and tends to fluctuate during the course of the day
 Ther is evidence from the history, physical examination, or
laboratory findings that the disturbance is cause by the direct
physiological consequences of a general medical condition.

Includes Substance Intoxication Delirium, and Substance
Withdrawal Delirium
Delirium – Case #1
 A 75-year old male with a history of coronary
artery disease, hypertension and atrial
fibrillation is brought to the ER by his wife
because of lethargy and confusion. The
patient’s wife states that the patient tripped on
the cat four days earlier and fell, but “didn’t
hurt himself”. Otherwise, he’s had no recent
changes in medications, no recent fevers.
Subdural hematoma
CNS abnormalities as cause of
Delirium
 Intracranial hemorrhage

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Subdural hematoma
Epidural hematoma
 Cerebral Vascular Accident

Ischemic or hemorrhagic stroke
 Seizure

Post-ictal confusion
 Brain tumors

Carcinomatous meningitis
 Vasculitis
Delirium – Case # 2
A 20-year old Georgetown student is brought to
Georgetown emergency room by his friend
because he was found to be confused and
lethargic. In the E.R. he is noted to have
fever to 103°, nuchal rigidity on exam, and
the following rash.
Delirium – Case # 2
CNS Infections as cause of delirium
 Meningitis
 Bacteria: Neisseria meningitides, Strep. pneumoniae,
Haemophilus influenzae, Listeria monocytogenes (in
elderly).
 Viruses: Enterovirus, Herpes simplex Virus (HSV),
Cytomegalovirus
 HIV: Crytpococcus
 Encephalitis
 HSV
 Frequently “wacky” behavior for days to hours before
hospitalization
 Brain abscess
 Infection with toxoplasmosis in HIV
Delirium Case # 3
A 34-year old male with no significant pastmedical history presents to Georgetown ER
after some lethargy and confusion right after
finishing his first marathon. His friends state
that he “never” drinks or uses drugs, and that
he did a very good job of keeping hydrated
with water and gatorade during the marathon.
Electrolyte abnormalities as cause of
Delirium
 Hyponatremia


Polydypsia (w/ free water)
SIADH
 Hypernatremia

Diabetes insipidus
 Hypercalcemia

Think of cancers: Squamous cell lung cancer,
Multiple myeloma
 Hypoglycemia
 Uremia
Systemic Infections as cause of
delirium
 Urinary Tract Infections
 Pneumonia
 Intra-abdominal infections
 Line infections
 Sepsis

Hypoperfusion to the brain results in decreased
mental status.
Delirium Case # 4
 An 88-year-old nursing home resident with a
history of hypertension, Diabetes mellitus and
an indwelling foley secondary to neurogenic
bladder, presents to the ER with obtundation.
She is noted on exam to have a low
temperature at 34.7° C, a blood pressure of
88/40 and very cloudy urine in her foley.
Delirium Case # 5
 A 56-year-old male with a history of 2 packs of
cigarettes/day for 40 years, and a history of a
“clotting disorder” presents to the ER with one day of
lethargy and confusion. On exam, the patient is
afebrile, normotensive with a HR of 110, respiratory
rate of 14 and Oxygen saturation of 92% on RA. In
general he is oriented to self only, but does not
appear to breathing heavily – in NAD. On lung exam
there are decreased breath sounds bilaterally. His
left lower extremity is noted to be more swollen than
the right.
Respiratory abnormalities as cause of
dementia
 Hypoxia



Asthma
Pulmonary Embolism
Pulmonary Edema (Congestive Heart Failure)
 Hypercapnia


COPD patients
Narcotic overdose
Delirium Case #6
 A 18-year old Georgetown college student is
brought in to Georgetown ER by the GUTS
emergency medical service. He was found
staggering down Prospect St. at 3 am. On
exam, patient is afebrile, normotensive,
slightly tachycardic, and very beligerant. He
has slurred speech, and is oriented to self
only. Nausea and vomiting along with fecal
incontinence ensues.
Drugs as cause for Delirium
 Alcohol
 D-Lysergic acid diethylamide (LSD)
 Benzodiazepines
 Narcotics
 PCP
Delirium Case # 7
 An 88-year old female with a history of osteoporosis
is brought to GUH by her granddaughter. The
granddaughter states that the patient is usually
“totally with it” and lives by herself. They spent the
day yesterday picnicking in a field in Northern
Virginia, and they had noticed some mosquitos bites
afterwards, but that was it. Starting today, the patient
was noticed to be acting very “wacky”. She also
hadn’t gone to the bathroom all day the
granddaughter states.
 On exam the patient is afebrile, but tachycardic; Her
mucus membranes are very dry, and she has
mydrasis.
Delirium Case # 8
 A 42-year old female with a history of
metastatic breast cancer is admitted to GUH
with spinal cord compression. She is seen by
neurosurgery, and decision is made to defer
surgery but instead have patient undergo
radiation therapy. Patient is noted over the
next several days to have “wacky” behavior –
at times oriented to self and place only.
Medications as cause for delirium
 Anti-cholinergics


Benadryl
Tri-cyclic antidepressants
 Muscle relaxants

Flexeril, skelaxin
 Anti-emetics

Phenergan
 Steroids

“steroid psychosis”
 Anesthesia Medications
Final Case
 A 79-year old female with a history of
hypertension, peripheral vascular disease
presents to the hospital with some mild
confusion. The patient and her daughter
states that since earlier that day, the patient
has been forgetting things, and had a few
episodes of not knowing where she was. She
has had no recent changes in medications,
no recent hospitalizations.
Final Case (cont.)
 PMH:


Hypertension
Peripheral Vascular Disease – had a femoral-popliteal
bypass in right leg 3 years ago
 Allergies: NKDA
 Outpatient Meds:
 Lisinopril – 40 mg po QDay
 Metoprolol – 25 mg po BID
 Social History:
 Lives with daughter; No history of tobacco or alcohol
use; No other drug use; previously worked as history
teacher (retired many years ago)
Final Case (cont.)
 Review of systems:
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Gen: No fever, no weakness, no weight
loss/gain, no headache
CV: No chest pain, no palpitations
Resp: No cough, no SOB
GI: No abdominal pain, no nausea/vomiting,
no diarrhea, no constipation
Heme: No easy bleeding, bruising
Final Case (cont.)
 Physical Exam:
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VS: 37.6° C, 112/60, 62, 16, 94% on RA
Gen.: Alert, but oriented only to self and
place; at times seems to have trouble giving
details of her medical history
CV: RRR, no murmurs auscultated
Resp.: LCTA bilaterally
Abd: soft, nontender, NABS
Ext.: No LE edema
Final Case (cont.)
 Labs:
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

WBC: 9.8
Hgb.: 11.2 Hct. 33.8
Plt: 228
Sodium: 132, Potassium: 4.0, Chloride: 100
CO2: 21, BUN 13, Cr. 0.8, Glucose 110
Urinalysis: No protein, glucose, ketones;
Leuk. Est: neg. , no WBCs, no RBCs
Final Case (cont.)
Final Case
Delirium Cases -- Synopsis
 CNS Process
 Medications
 CNS Infections
 Alcohol/Drugs
 Infections/Sepsis
 Hypoxia/Hypercapnia
 Electrolye Disturbances
 Hyponatremia
 Hypoglycemia
 Hypercalcemia
 Myocardial Infarction