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27 Cards in this Set

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Delirium Definition

1. Disturbance of cognition

2. Fluctuation

3. Reduced awareness

4. Change in psychomotor behavior

Delirium: Disturbance of cognition

Reduced ability to direct, focus, sustain, or shift attention

Sudden profound impact on other domains

Often unable to maintain coherent stream of thought or action

Highly distractible

Delirium: Fluctuation

Level of attention and orientation to the environment throughout the day

Somnolence and excessive alertness, intense agitation, frenzied excitement

+ hyperactive and - hypoactive features

Disturbance of mood and sleep-wake cycles

Delirium: Reduced Awareness

Disorders of perception


Sensory illusions

Delusions and/or hallucinations are often erratic and nonsystematic

Delirium: Changes in psychomotor behavior

hyperkinetic, hypokinetic or mixed presentation

Hyper - Increased motor activity, restlessness, stereotyped behaviors, and psychomotor agitation

Hypo - Lethargy, lack of initiation, and slow RT


A nonspecific term used to describe any medical condition impacting brain's function

Both acute and chronic conditions

Delirium: common causes




Acute Metabolic


CNS pathology


Deficiencies (Nutritional)


Acute vascular

Toxins or drugs

Heavy Metals

Delirium: Neuropathology

- Decrease in Ach - cholinergic deficiency hypothesis - contributes to impairments in attention and memory - reversed by eserine

- Excess dopamine or enhanced receptor site sensitivity - thought to cause hallucinations - Levodopa can cause

- Disruption or overexcitation of serotonergic systems may cause hallucinations and emotional lability. - agitation, myclonus, hyperreflexia, diaphoresis, tremor, diarrhea, incoordination, fever (serotonin syndrome)

Delirium: Predisposing Factors

Age, medical comorbidities, cognitive and functional impairments, depression, sensory loss or dysfunction, respiratory failure, myocardial infarction, infection

-Preexisting brain disease: reduced cognitive reserve

-age: change in vasculature, decreased Ach, increased MAOi

-comorbid physical problems: sleep deprivation, sensory impairment, immobility

-medical comorbidities: chronic or poorly controlled conditions

Delirium: Precipitating Factors

Major surgery, anticholinergic drugs, drug withdrawal, infections, iatrogenic complications, metabolic derangements, pain

-postoperative states and complications such as hyponatremia

-Acute injuries: or medical procedures that do not directly affect the CNS that result in metabolic issues

Delirium Rates

1-2% of population

Young - toxic iatrogenic drugs or illicit drug use

Older - med side effects; 35% after vascular 40-60% after hip

50% experience permanent cog impairment after resolution

80% of patients experience in stages prior to death

Delirium: Severity

Life threatening condition

*multisystem organ failure

*Sustained autonomic hyperarousal and/or storms despite treatment

*Status epilepticus or multiple treatment-resistant seizures

*Wernicke's encephalopathy and/or delirium tremens

*Chronic, uncorrected metabolic distrubance or physiologic condision

Delirium: Course

Abrupt Onset

TBI, stroke, sudden event results in immediate confusion and behavioral changed. Typically steady recovery

Delirium: Course

Slow-onset/fluctuating course

Develop over hours or days (developing metabolic disturbance) Sx often wax and wane, islands of lucidity, wide variety of outcomes

Delirium: Assessment

* Assume reversible and work together to ID and reverse etiology

*Determine if MD's reviewed meds and interactions

*Determine if MD's checked for infection or medical cause

*Review clinician and collatoral reports for infection or medical cause

*Review labs

*Review neuroimaging and abnormal EEG

*Monitor confusion with periodic reassessment

Delirium: Psychiatric Features

Consciousness and cognition not as severely impaired as in delirium

Hallucinations and delusions typically more consistent and systematic compared to delirium

Delirium: Treatment

Correct all possible causative factors

ER - give thiamine followed by glucose

Adequate hydration, nutrition, airway

Vitals monitored closely

Prevent complications

Delirium: NP expectations

bedside exam and bg info

IQ - decreased fxn, some return to baseline others have decreased fluid intelligence

Attn - sig difficulty sustained, moments of clarity, distractible

PS - mod/sev impairment; deficits apparent during lucid moment on formal evaluation

Lang - fluent aphasia in some mute, dysnomia

VS - commonly affected and likely due to decreased attn/EF

Mem - disorientation of time/place common, mem impaired

EF - always impaired, decreased flex, judge, reason, disorganized thoughts

SM - changes in reflexes and tone

Emo - dramatic changes

Delirium: Considerations







Functional issues


Formication Hallucinations

Bugs on skin

Often reported in drug withdrawal

When unilateral suggests focal parietal or thalamic lesions

Visceral Hallucinations

Sensations that are believed to stem from internal organs

Typically unpleasant and difficulty to localize

Psychiatric or neurologic conditions

Hypnagogic Hallucinations

Occur in the presence of falling asleep

Hypnopompic Hallucinations

Occur in process of awakening

Often coincide with sleep paralysis


Perception that one's body is changing in size or shape.

Alice in wonderland system


A fixed delusional belief that objects, people, or places have been duplicated

Capgras Syndrome - belief that a person has been replaced by an imposter

Reduplicative paramnesia - belief that a place has been replaced and duplicated.

Peduncular Hallucinations

Vivid, motion-filled hallucinations that include the perception of small objects, animals, people, or familiar landscapes.

Often pleasant or entertaining but can become anxiety provoking

Typically associated with lesions involving the posterior circulation

Release Hallucinations

Occur as consequence of sensory loss and subsequent disengagement of higher cerebral systems

Palinopsia - visual image continues to appear to be re-experienced hours or days after it is no longer present