PART 3 / CH 30
Delirium
Roy Perlis
A. Definition (DSM-IV)
1. disturbed consciousness with impaired attention
2. impaired cognition or perception
3. acute onset (hrs-days) with fluctuating course
(best bedside tests: clock-drawing, go/no-go)
B. Common associated features
1. increased or decreased psychomotor activity
2. fearfulness/paranoia/lability
3. disturbed sleep-wake cycle
4. misperceptions, visual hallucinations
C. Life-threatening etiologies: OHHH, SHIT!
| etiology | evaluation | |
|---|---|---|
| O | hypoxia | O2 sat |
| H | hypoperfusion | HR/bp |
| H | hypertensive encephalopathy | |
| H | hypoglycemia | FS-glucose |
| S | stroke | imaging |
| H | hemorrhage (intracranial) | imaging |
| I | infection (meningitis, encephalitis) | temp., WBC |
| T | toxins (barbiturate w.d., Wernicke’s, CO, …) | labs |
D. Medications commonly associated with delirium
1. anticholinergics/ antihistamines
2. narcotics, especially demerol (normeperidine)
3. antiarrhythmics, antihypertensives, beta blockers
4. antibiotics (penicillin, rifampin)
5. corticosteroids
6. anticonvulsants, neuroleptics (anticholinergic), lithium
E. Differential diagnosis
| Type | Examples |
|---|---|
| Medications | see table |
| Intoxication/Withdrawal | alcohol, benzodiazepines, barbiturates, narcotics, PCP, hallucinogens |
| Intracranial | seizure or postictal state hemorrhage, hypertensive encephalopathy, stroke neoplasm (primary/metastatic) infection (meningitis/encephalitis, HIV, neurosyph.) NPH |
| Metabolic | renal failure (uremia), hepatic failure hypoglycemia, diabetic ketoacidosis fluid, acid-base or electrolyte disturbance parathyroid/thyroid/adrenal dysfunction thiamine deficiency (Wernicke’s) |
| Cardiovasc. | myocardial infarction, CHF, arrhythmia respiratory failure, hypoxia, anemia |
| Systemic | infection (any, including endocarditis) paraneoplastic, postoperative |
source: Trepacz P et al. (1999) Am J Psychiatry 156:5 (supplement)