Hostname: page-component-78c5997874-lj6df Total loading time: 0 Render date: 2024-11-16T17:03:45.605Z Has data issue: false hasContentIssue false

Delirium: A Review

Published online by Cambridge University Press:  02 December 2014

Teneille Emma Gofton*
Affiliation:
Memorial Sloan-Kettering Cancer Center, New York, New York, USA
*
Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, New York, 10065, USA
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

Delirium affects a diverse patient population, may present with highly variable clinical features, is a source of distress for patients and their caregivers, prolongs hospital stays and may herald a poor prognosis. Many cases of delirium are reversible and therefore a full history, physical examination and investigations should be performed. A high degree of suspicion is required for detecting delirium and thorough investigations are necessary in order to determine the underlying etiology and to maximize the potential for reversibility. The following review outlines important aspects of a clinical approach to delirium, the differential diagnosis of delirium, investigation of a patient presenting with delirium, management of delirium, the pathophysiology of delirium and the prognosis accompanying delirium.

Type
Review Article
Copyright
Copyright © The Canadian Journal of Neurological 2011

References

1.Inouye, SK, Rushing, JT, Foreman, MD, Palmer, RM, Pompei, P.Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med. 1998;13(4):2342.CrossRefGoogle ScholarPubMed
2.McCusker, J, Cole, M, Dendukuri, N, Belzile, E, Primeau, F.Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study. CMAJ. 2001;165(5):57583.Google ScholarPubMed
3.Samuels, SC, Evers, MM.Delirium. Pragmatic guidance for managing a common, confounding, and sometimes lethal condition. Geriatrics. 2002;57(6):338.Google ScholarPubMed
4.Bruera, E, Bush, SH, Willey, J, et al.Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers. Cancer. 2009;115(9):200412.CrossRefGoogle ScholarPubMed
5.Morita, T, Hirai, K, Sakaguchi, Y, Tsuneto, S, Shima, Y.Familyperceived distress from delirium-related symptoms of terminally ill cancer patients. Psychosomatics. 2004;45(2):10713.CrossRefGoogle ScholarPubMed
6.Breitbart, W, Gibson, C, Tremblay, A.The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses. Psychosomatics. 2002;43(3):18394.CrossRefGoogle ScholarPubMed
7.http://www.psych.org [homepage on the Internet]. Diagnostic and Statistical Manual-5, proposed revisions. Virginia, USA: American Psychiatric Association Press; c2011 [cited 2011 March 24]. Available from: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=32Google Scholar
8.Bourgeois, JA, Seritan, SA.Diagnosis and management of delirium. Continuum. 2006;12(18).Google Scholar
9.Khan, J, Harrison, HT.Central and peripheral neurologic manifestations of critical medical illness. Continuum. 2008;14(19).Google Scholar
10.Fang, CK, Chen, HW, Liu, SI, Lin, CJ, Tsai, LY, Lai, YL.Prevalence, detection and treatment of delirium in terminal cancer inpatients: a prospective survey. Jpn J Clin Oncol. 2008;38(1):5663.CrossRefGoogle ScholarPubMed
11.Guidotti, M, Chiveri, L, Mauri, M.Acute encephalopathies. Neurol Sci. 2006;27 Suppl 1:S556.CrossRefGoogle ScholarPubMed
12.Inouye, SK, Charpentier, PA.Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275(11):8527.CrossRefGoogle ScholarPubMed
13.Levkoff, S, Cleary, P, Liptzin, B, Evans, DA.Epidemiology of delirium: an overview of research issues and findings. Int Psychogeriatr. 1991;3(2):14967.CrossRefGoogle ScholarPubMed
14.http://www.uptodate.com http://www.uptodate.com. Francis, JF, Young, GB.Diagnosis of delirium and confusional states .Massachussetts, USA: UpToDate, Inc; c2011 [cited 2010 December 9]. Available from: http://www.uptodate.com.Google Scholar
15.Gaudreau, JD, Gagnon, P, Harel, F, Roy, MA, Tremblay, A.Psychoactive medications and risk of delirium in hospitalized cancer patients. J Clin Oncol. 2005; 23(27):671218.CrossRefGoogle ScholarPubMed
16.Gaudreau, JD, Gagnon, P, Roy, MA, Harel, F, Tremblay, A.Association between psychoactive medications and delirium in hospitalized patients: a critical review. Psychosomatics. 2005;46(4):30216.CrossRefGoogle ScholarPubMed
17.Sprung, CL, Cerra, FB, Freund, HR, et al.Amino acid alterations and encephalopathy in the sepsis syndrome. Crit Care Med. 1991;19(6):7537.CrossRefGoogle ScholarPubMed
18.Mizock, BA, Sabelli, HC, Dubin, A, Javaid, JI, Poulos, A, Rackow, EC.Septic encephalopathy. Evidence for altered phenylalanine metabolism and comparison with hepatic encephalopathy. Arch Intern Med. 1990;150(2):4439.CrossRefGoogle ScholarPubMed
19.Bruera, E, Miller, L, McCallion, J, Macmillan, K, Krefting, L, Hanson, J.Cognitive failure in patients with terminal cancer: a prospective study. J Pain Symptom Manage. 1992;7(4):1925.CrossRefGoogle ScholarPubMed
20.Lawlor, PG, Gagnon, B, Mancini, IL, et al.Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Arch Intern Med. 2000;160(6):78694.CrossRefGoogle ScholarPubMed
21.Pereira, J, Hanson, J, Bruera, E.The frequency and clinical course of cognitive impairment in patients with terminal cancer. Cancer. 1997;79(4):83542.3.0.CO;2-#>CrossRefGoogle ScholarPubMed
22.Jackson, JC, Gordon, SM, Hart, RP, Hopkins, RO, Ely, EW.The association between delirium and cognitive decline: a review of the empirical literature. Neuropsychol Rev. 2004;14(2):8798.CrossRefGoogle ScholarPubMed
23.Practice guideline for the treatment of patients with delirium. American Psychiatric Association. Am J Psychiatr. 1999;156(5 Suppl):120.Google Scholar
24.www.psych.org [homepage on the Internet]. Cook I. Guideline Watch: Practice guidelines for the treatment of patients with delirium. Virginia, USA: American Psychiatric Association Press; c2011 [cited 2011 March 24]. Available from: http://www.psychiatryonline.com/pracGuide/PracticePDFs/Delirium.watch.pdf.Google Scholar
25.van den Boogaard, M, Pickkers, P, van der Hoeven, H, Roodbol, G, vanAchterberg, T, Schoonhoven, L.Implementation of a delirium assessment tool in the ICU can influence haloperidol use. Crit Care. 2009;13(4):R131.CrossRefGoogle ScholarPubMed
26.Hart, RP, Levenson, JL, Sessler, CN, Best, AM, Schwartz, SM, Rutherford, LE.Validation of a cognitive test for delirium in medical ICU patients. Psychosomatics. 1996;37(6):53346.CrossRefGoogle ScholarPubMed
27.Inouye, SK, van Dyck, CH, Alessi, CA, Balkin, S, Siegal, AP, Horwitz, RI.Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):9418.CrossRefGoogle Scholar
28.Robertsson, B, Karlsson, I, Styrud, E, Gottfries, CG.Confusional State Evaluation (CSE): an instrument for measuring severity of delirium in the elderly. Br J Psychiatry. 1997;170:56570.CrossRefGoogle ScholarPubMed
29.Schuurmans, MJ, Shortridge-Baggett, LM, Duursma, SA.The Delirium Observation Screening Scale: a screening instrument for delirium. Res Theory Nurs Pract. 2003;17(1):3150.CrossRefGoogle Scholar
30.Trzepacz, PT, Baker, RW, Greenhouse, J.A symptom rating scale for delirium. Psychiatry Res. 1988;23(1):8997.CrossRefGoogle ScholarPubMed
31.Trzepacz, PT, Dew, MA.Further analyses of the Delirium Rating Scale. Gen Hosp Psychiatry. 1995;17(2):759.CrossRefGoogle ScholarPubMed
32.Albert, MS, Levkoff, SE, Reilly, C, et al.The delirium symptom interview: an interview for the detection of delirium symptoms in hospitalized patients. J Geriatr Psychiatry Neurol. 1992;5(1):1421.CrossRefGoogle ScholarPubMed
33.Bergeron, N, Dubois, MJ, Dumont, M, Dial, S, Skrobik, Y.Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intens Care Med. 2001;27(5):85964.CrossRefGoogle ScholarPubMed
34.Breitbart, W, Rosenfeld, B, Roth, A, Smith, MJ, Cohen, K, Passik, S.The Memorial Delirium Assessment Scale. J Pain Symptom Manage. 1997;13(3):12837.CrossRefGoogle ScholarPubMed
35.Neelon, VJ, Champagne, MT, Carlson, JR, Funk, SG.The NEECHAM Confusion Scale: construction, validation, and clinical testing. Nurs Res. 1996;45(6):32430.CrossRefGoogle ScholarPubMed
36.Kaplan, PW.The EEG in metabolic encephalopathy and coma. J Clin Neurophysiol. 2004;21(5):30718.Google ScholarPubMed
37.Sagawa, R, Akechi, T, Okuyama, T, Uchida, M, Furukawa, TA.Etiologies of delirium and their relationship to reversibility and motor subtype in cancer patients. Jpn J Clin Oncol. 2009;39(3):17582.CrossRefGoogle ScholarPubMed
38.Moyer, DD.Terminal delirium in geriatric patients with cancer at end of life. Am J Hosp Palliat Care. 2011;28(1):4451.CrossRefGoogle ScholarPubMed
39.Gaudreau, JD, Gagnon, P.Psychotogenic drugs and delirium pathogenesis: the central role of the thalamus. Med Hypotheses. 2005;64(3):4715.CrossRefGoogle ScholarPubMed
40.Trzepacz, PT.Is there a final common neural pathway in delirium? Focus on acetylcholine and dopamine. Semin Clin Neuropsychiatry. 2000;5(2):13248.Google Scholar
41.Tune, LE, Damlouji, NF, Holland, A, Gardner, TJ, Folstein, MF, Coyle, JT.Association of postoperative delirium with raised serum levels of anticholinergic drugs. Lancet. 1981;2(8248):6513.CrossRefGoogle ScholarPubMed
42.Flacker, JM, Cummings, V, Mach, JR Jr., Bettin, K, Kiely, DK, Wei, J.The association of serum anticholinergic activity with delirium in elderly medical patients. Am J Geriatr Psychiatry. 1998;6(1):3141.CrossRefGoogle ScholarPubMed
43.Caplan, LR.Cardiac encephalopathy and congestive heart failure: a hypothesis about the relationship. Neurology. 2006;66(1):99101.CrossRefGoogle ScholarPubMed
44.Pugsley, W, Klinger, L, Paschalis, C, Treasure, T, Harrison, M, Newman, S.The impact of microemboli during cardiopulmonary bypass on neuropsychological functioning. Stroke. 1994;25(7):13939.CrossRefGoogle ScholarPubMed
45.Kunze, K.Metabolic encephalopathies. J Neurol. 2002;249(9):11509.CrossRefGoogle ScholarPubMed
46.Wilson, JX, Young, GB.Progress in clinical neurosciences: sepsisassociated encephalopathy: evolving concepts. Can J Neurol Sci. 2003;30(2):98105.CrossRefGoogle ScholarPubMed
47.Dasgupta, M, Hillier, LM.Factors associated with prolonged delirium: a systematic review. Int Psychogeriatr. 2010;22(3):37394.CrossRefGoogle ScholarPubMed
48.Michaud, L, Burnand, B, Stiefel, F.Taking care of the terminally ill cancer patient: delirium as a symptom of terminal disease. Ann Oncol. 2004;15 Suppl 4:iv199203.CrossRefGoogle ScholarPubMed
49.Breitbart, W, Alici, Y.Agitation and delirium at the end of life: “We couldn’t manage him”. JAMA. 2008;300(24):2898910, E1.Google Scholar
50.van Munster, BC, de Rooij, SE, Korevaar, JC.The role of genetics in delirium in the elderly patient. Dement Geriatr Cogn Disord. 2009;28(3):18795.CrossRefGoogle ScholarPubMed
51.Hshieh, TT, Fong, TG, Marcantonio, ER, Inouye, SK.Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence. J Gerontol A Biol Sci Med Sci. 2008;63(7):76472.CrossRefGoogle ScholarPubMed
52.Cerejeira, J, Firmino, H, Vaz-Serra, A, Mukaetova-Ladinska, EB.The neuroinflammatory hypothesis of delirium. Acta Neuropathol. 2010;119(6):73754.CrossRefGoogle ScholarPubMed
53.van Munster, BC, Korevaar, JC, Zwinderman, AH, Levi, M, Wiersinga, WJ, De Rooij, SE.Time-course of cytokines during delirium in elderly patients with hip fractures. J Am Geriatr Soc. 2008;56(9):17049.CrossRefGoogle ScholarPubMed
54.Dantzer, R, O’Connor, JC, Freund, GG, Johnson, RW, Kelley, KW.From inflammation to sickness and depression: when the immune system subjugates the brain. Nat Rev Neurosci. 2008;9(1):4656.CrossRefGoogle ScholarPubMed
55.Shih, HT, Huang, WS, Liu, CH, et al.Confusion or delirium in patients with posterior cerebral arterial infarction. Acta Neurol Taiwan. 2007;16(3):13642.Google ScholarPubMed
56.Siddiqi, N, Holt, HR, Britton, AM, Holmes, J.Interventions for preventing delirium in hospitalised patients. Cochrane DB Syst Rev. 2007(2).CrossRefGoogle ScholarPubMed
57.Inouye, SK, Bogardus, ST Jr, Charpentier, PA, et al.A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):66976.CrossRefGoogle ScholarPubMed
58.Sechi, G, Serra, A.Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol. 2007;6(5):44255.CrossRefGoogle ScholarPubMed
59.Lonergan, E, Luxenberg, J.Antipsychotics for delirium. Cochrane DB Syst Rev. 2007(2).CrossRefGoogle ScholarPubMed
60.Tesar, GE, Murray, GB, Cassem, NH.Use of high-dose intravenous haloperidol in the treatment of agitated cardiac patients. J Clin Psychopharmacol. 1985;5(6):3447.CrossRefGoogle ScholarPubMed
62.Meyer-Massetti, C, Cheng, CM, Sharpe, BA, Meier, CR, Guglielmo, BJ.The FDA extended warning for intravenous haloperidol and torsades de pointes: how should institutions respond? J Hosp Med. 2010;5(4):E816.CrossRefGoogle ScholarPubMed
63.Narang, P, El-Refai, M, Parlapalli, R, et al.Antipsychotic drugs: sudden cardiac death among elderly patients. Psychiatry. (Edgmont) 2010;7(10):259.Google ScholarPubMed
64.Schwartz, TL, Masand, PS.The role of atypical antipsychotics in the treatment of delirium. Psychosomatics. 2002;43(3):1714.CrossRefGoogle ScholarPubMed
65.Alici-Evcimen, Y, Breitbart, W.An update on the use of antipsychotics in the treatment of delirium. Palliat Support Care. 2008;6(2):17782.CrossRefGoogle ScholarPubMed
66.Passik, SD, Cooper, M.Complicated delirium in a cancer patient successfully treated with olanzapine. J Pain Symptom Manage. 1999;17(3):21923.CrossRefGoogle Scholar
67.Schwartz, TL, Masand, PS.Treatment of delirium with quetiapine. Prim Care Companion J Clin Psychiatry. 2000;2(1):1012.Google ScholarPubMed
68.Sipahimalani, A, Masand, PS.Use of risperidone in delirium: case reports. Ann Clin Psychiatry. 1997;9(2):1057.CrossRefGoogle ScholarPubMed
69.Lonergan, E, Luxembourg, LJ, Areosa Sastre, A.Benzodiazepines for delirium. Cochrane DB Syst Rev. 2009(4).CrossRefGoogle ScholarPubMed
70.Overshott, R KS, Burns, A.Cholinesterase inhibitors for delirium. Cochrane DB Syst Rev. 2008(1).Google ScholarPubMed
71.Paris, A, Tonner, PH.Dexmedetomidine in anaesthesia. Curr Opin Anaesthesiol. 2005;18(4):41218.CrossRefGoogle ScholarPubMed
72.Venn, RM, Bradshaw, CJ, Spencer, R, et al.Preliminary UK experience of dexmedetomidine, a novel agent for postoperative sedation in the intensive care unit. Anaesthesia. 1999;54(12):113642.CrossRefGoogle ScholarPubMed
73.Pandharipande, PP, Pun, BT, Herr, DL, et al.Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA. 2007;298(22):264453.CrossRefGoogle Scholar
74.Riker, RR, Shehabi, Y, Bokesch, PM, et al.Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA. 2009;301(5):48999.CrossRefGoogle ScholarPubMed
75.Sichrovsky, TC, Mittal, S, Steinberg, JS.Dexmedetomidine sedation leading to refractory cardiogenic shock. Anesth Analg. 2008;106(6):17846.CrossRefGoogle ScholarPubMed
76.Tan, JA, Ho, KM.Use of dexmedetomidine as a sedative and analgesic agent in critically ill adult patients: a meta-analysis. Intens Care Med. 2010;36(6):92639.CrossRefGoogle ScholarPubMed
77.Jackson, KC, Lipman, LA.Drug therapy for delirium in terminally ill adult patients. Cochrane DB Syst Rev. 2004(2).Google Scholar
78.Schwartzstein, RM, Lahive, K, Pope, A, Weinberger, SE, Weiss, JW.Cold facial stimulation reduces breathlessness induced in normal subjects. Am Rev Respir Dis. 1987;136(1):5861.CrossRefGoogle ScholarPubMed
79.Cole, MG, Primeau, FJ, Bailey, RF, et al.Systematic intervention for elderly inpatients with delirium: a randomized trial. CMAJ. 1994;151(7):96570.Google ScholarPubMed
80.Pitkala, KH, Laurila, JV, Strandberg, TE, Tilvis, RS.Multicomponent geriatric intervention for elderly inpatients with delirium: a randomized, controlled trial. J Gerontol A Biol Sci Med Sci. 2006;61(2):17681.CrossRefGoogle ScholarPubMed
81.Milisen, K, Lemiengre, J, Braes, T, Foreman, MD.Multicomponent intervention strategies for managing delirium in hospitalized older people: systematic review. J Adv Nurs. 2005;52(1):7990.CrossRefGoogle ScholarPubMed
82.Kobayashi, K, Takeuchi, O, Suzuki, M, Yamaguchi, N.Aretrospective study on delirium type. Jpn J Psychiatry Neurol. 1992;46(4):91117.Google Scholar
83.Marcantonio, ER, Flacker, JM, Michaels, M, Resnick, NM.Delirium is independently associated with poor functional recovery after hip fracture. J Am Geriatr Soc. 2000;48(6):61824.CrossRefGoogle ScholarPubMed
84.Dubois, MJ, Bergeron, N, Dumont, M, Dial, S, Skrobik, Y.Delirium in an intensive care unit: a study of risk factors. Intens Care Med. 2001;27(8):1297304.CrossRefGoogle Scholar
85.Girard, TD, Jackson, JC, Pandharipande, PP, et al.Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med. 2010;38(7):151320.CrossRefGoogle ScholarPubMed
86.Andrew, MK, Freter, SH, Rockwood, K.Prevalence and outcomes of delirium in community and non-acute care settings in people without dementia: a report from the Canadian Study of Health and Aging. BMC Med. 2006;4:15.CrossRefGoogle ScholarPubMed
87.Leonard, M, Raju, B, Conroy, M, et al.Reversibility of delirium in terminally ill patients and predictors of mortality. Palliat Med. 2008;22(7):84854.CrossRefGoogle ScholarPubMed