Management of delirium

• Delirium, otherwise known as acute confusional state, is an acute, reversible, global disorder of the higher nervous system function.

• It is common in the inpatient setting but is often undiagnosed in its early stages and may therefore present as a medical emergency.

• If not managed appropriately, it is associated with significant mortality. Early detection and treatment are therefore of paramount importance.

• Almost any acute, severe, medical or surgical condition can cause delirium. Although its pathogenesis is still poorly understood, it is generally held to represent widespread dysfunction of cerebral oxidative metabolism.

• Diagnosis of the condition involves two stages: first, the clinical syndrome itself is identified; second, the responsible aetiological agent is sought.

• Central features of the clinical syndrome (Box 4.1) are fluctuating impairments in consciousness and attention, disturbance of sleep-wake cycle with nocturnal worsening, overactivity or underactivity, disorganised thinking and speech, disorientation for time and place, and often paranoid delusions and visual hallucinations. The natural history is one of sudden onset with a fluctuating course.

• An aetiological diagnosis can be made in most patients by appropriate physical examination and investigation as suggested by the history, although a detailed test screen may be needed in a few cases. Overinvestigation is preferable to underinvestigation, given that individual cases of delirium may be caused by multiple factors.

• In those few remaining cases where the aetiological agent remains unidentified, care must be taken to exclude other psychiatric diagnoses that may occasionally mimic delirium, such as certain forms of dementia, schizophrenia, mania, depression, and dissociative disorder. Use your liaison psychiatric service.

• The proper management of delirium consists of providing general supportive measures along with treatment directed against the primary cause. Supportive measures should not be withheld until the aetiological factors have been identified, as delay may result in a deterioration in the patient's condition.

• The patient should be nursed in a well lit side room by a small group of key personnel, as overstimulation or understimulation of his or her sensory environment may exacerbate the delirium.

• Attention should be paid to nutrition, fluid, and electrolyte intake, and in those patients who are relatively immobile, physiotherapy should be instituted to avoid such potential consequences as deep venous thrombosis, pressure necrosis, and chest infection.

• Iatrogenic factors may be important in some cases and the patient's drug chart should be fully reviewed.

• Sedation should be used carefully; it may worsen the delirium if prescribed inappropriately. In those cases where sedation is necessary, such as when the patient becomes a danger to him- or herself or to others, the choice of drug is ideally informed by a knowledge of the underlying causative factors.

• Benzodiazepines are the best drugs in withdrawal states. In most other cases, butyrophenones are to be preferred. In general, mild to moderate degrees of agitation will respond to oral haloperidol whereas moderate to severe degrees require intramuscular haloperidol.

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