We need you! Join our contributor community and become a WikEM editor through our open and transparent promotion process.
Delirium
From WikEM
Contents
Background
- Also known as "acute toxic-metabolic encephalopathy"
- Delirium vs. dementia vs. psych
Clinical Features
- Main cognitive impairment is that of inattention (vs memory in dementia)
- Generally develops over hours to days
- Symptoms are classically described as fluctuating throughout the day (ie may appear normal in between episodes)
ED Confusion Assessment Method[1]
- Acute onset of mental status changes and/or fluctuating course
- Anattention
- Disorganized thinking
- Altered level of consciousness
A patient must possess both features 1 and 2 AND either 3 or 4 to meet delirium criteria
Differential Diagnosis
Altered mental status
Diffuse brain dysfunction
- Hypoxic encephalopathy
- Acute toxic-metabolic encephalopathy (Delirium)
- Hypoglycemia
- Hyperosmolar state (e.g., hyperglycemia)
- Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
- Organ system failure
- Hepatic Encephalopathy
- Uremia/Renal Failure
- Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
- Hypoxia
- CO2 narcosis
- Hypertensive Encephalopathy
- Toxins
- Drug reactions (NMS, Serotonin Syndrome)
- Environmental causes
- Deficiency state
- Wernicke encephalopathy
- Subacture Combined Degeneragion (B12 deficiency)
- Vitamin D Deficiency
- Zinc Deficiency
- Sepsis
Primary CNS disease or trauma
- Direct CNS trauma
- Diffuse axonal injury
- Subdural/epidural hematoma
- Vascular disease
- Intraparenchymal hemorrhage
- SAH
- Stroke
- Hemispheric, brainstem
- CNS infections
- Neoplasms
- Paraneoplastic Limbic Encephalitis]
- Malignant Meningitis
- Pancreatic Insulinoma
- Seizures
- Nonconvulsive status epilepticus
- Postictal state
- Dementia
Psychiatric
- Acute psychosis
- Excited delirium
- Malingering
General Psychiatric
- Organic causes
- Psychiatric causes
Evaluation
Main goal is to find the underlying cause
AMS Workup
Common Orders
Consider Based on Clinical Situation
- Blood and urine cultures
- Ammonia level
- Tylenol/Aspirin level
- LP
- Serum Osm
- Coags
- Cortisol
- ABG/VBG
- CO level
Management
- Treat underlying cause
- Antipsychotics (eg haloperidol, risperidone) may be useful for hyperactive delirium with psychotic features
Disposition
- Admission
See Also
References
- ↑ Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113:941.
