Box 43 Causes of delirium

Primary central nervous system causes: Head injury

Cerebrovascular: stroke, subdural haematoma, transient ischaemic attack

Raised intracranial pressure

Intracranial infection: encephalitis, meningitis

Epilepsy: ictal, postictal

Secondary to systemic illness:

Infections: chest, urinary tract, septicaemia, malaria, HIV Cardiovascular: infarction, cardiac failure, arrhythmia Metabolic: hypo/hyperglycaemia, uraemia, hepatic failure, electrolyte disturbances

Endocrine: Addisonian crisis, disturbance of thyroid, parathyroid Alcohol: Wernicke's encephalopathy, delirium tremens Prescribed drugs: psychotropic drugs, steroids, digoxin, cimetidine, anticonvulsants, anticholinergics, overdosage Illicit drugs

Rare causes:

Systemic lupus erythematosus, porphyria, vitamin B12 or folate deficiency, pellagra, heavy metal poisoning, hypothermia, Wilson's disease, remote effect of carcinoma, hypertensive encephalopathy the clinical diagnosis is not in doubt, yet the aetiological agent simply remains unidentified. It must also be remembered that more than one aetiological factor may be contributing to the patient's delirium, particularly in the elderly.32

The commonest causes of delirium include alcohol abuse and withdrawal, stroke, diabetes, ischaemic heart disease, pneumonia, and urinary tract infections.36 Almost any medically prescribed drug can cause delirium if taken in sufficient dose, but anticholinergic, psychotropic, and hypnotic agents are especially known for their propensity to provoke the disorder, particularly in the elderly.37

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