Delirium - American Academy of Family Physicians

Delirium is characterized by an acute change in cognition and a disturbance of consciousness, usually resulting from an underlying medical ... Advertisement <> Mar1,2003Issue    Delirium ONDRIAC.GLEASON,M.D.,UniversityofOklahomaCollegeofMedicine,Tulsa,OklahomaAmFamPhysician. 2003 Mar 1;67(5):1027-1034. Abstract AcuteOnset/FluctuatingLevelsofConsciousnessSubtypesofDeliriumScreeningToolsIndicationsofUnderlyingMedicalConditionsDifferentiatingDeliriumfromPrimaryPsychiatricDisorderRiskFactorsManagementReferencesArticleSections Abstract AcuteOnset/FluctuatingLevelsofConsciousnessSubtypesofDeliriumScreeningToolsIndicationsofUnderlyingMedicalConditionsDifferentiatingDeliriumfromPrimaryPsychiatricDisorderRiskFactorsManagementReferencesDeliriumischaracterizedbyanacutechangeincognitionandadisturbanceofconsciousness,usuallyresultingfromanunderlyingmedicalconditionorfrommedicationordrugwithdrawal.Deliriumaffects10to30percentofhospitalizedpatientswithmedicalillness;morethan50percentofpersonsincertainhigh-riskpopulationsareaffected.Theassociatedmorbidityandmortalitymakediagnosisofthisconditionextremelyimportant.Patientswithdeliriumcanpresentwithagitation,somnolence,withdrawal,andpsychosis.Thisvariationinpresentationcanleadtodiagnosticconfusionand,insomecases,incorrectattributionofsymptomstoaprimarypsychiatricdisorder.Tomakethedistinction,itisimportanttoobtainthehistoryoftheonsetandcourseoftheconditionfromfamilymembersorcaregivers.Primarycarephysiciansmustbeabletorecognizedeliriumsothattheunderlyingetiologycanbeascertainedandaddressed.Themanagementofdeliriuminvolvesidentifyingandcorrectingtheunderlyingproblem,andsymptomaticallymanaginganybehavioralorpsychiatricsymptoms.Lowdosesofantipsychoticdrugscanhelptocontrolagitation.Theuseofbenzodiazepinesshouldbeavoidedexceptincasesofalcoholorsedative-hypnoticwithdrawal.Environmentalinterventions,includingfrequentreorientationofpatientsbynursingstaffandeducationofpatientsandfamilies,shouldbeemployedinallcases. Withoutcarefulassessment,deliriumcaneasilybeconfusedwithanumberofprimarypsychiatricdisordersbecausemanyofthesignsandsymptomsofdeliriumarealsopresentinconditionssuchasdementia,depression,andpsychosis.Somecharacteristicsignsandsymptomsofdeliriumaredescribedinthisarticle.Allofthesesymptomsmaynotbepresentineverypatient.Thepresentationofapatientwithdeliriumwillfluctuateduringthecourseoftheconditionandevenduringthecourseofaday.ThediagnosticcriteriafordeliriumarelistedinTable1.1View/PrintTableTABLE1DiagnosticCriteriaforDeliriumA.Disturbanceofconsciousness(i.e.,reducedclarityofawarenessabouttheenvironment)withreducedabilitytofocus,sustain,orshiftattention.B.Achangeincognition(e.g.,memorydeficit,disorientation,languagedisturbance)ordevelopmentofaperceptualdisturbancethatisnotbetteraccountedforbyapreexisting,established,orevolvingdementia.C.Thedisturbancedevelopsoverashortperiodoftime(usuallyhourstodays)andtendstofluctuateduringthecourseofaday.D.Evidencefromthehistory,physicalexamination,orlaboratoryfindingsindicatethatthedisturbanceiscausedbydirectphysiologicconsequencesofageneralmedicalcondition.ReprintedwithpermissionfromDiagnosticandstatisticalmanualofmentaldisorders:DSM-IV-TR.Washington,D.C.,AmericanPsychiatricAssociation,2000:143.Copyright2000,AmericanPsychiatricAssociation.TABLE1DiagnosticCriteriaforDeliriumA.Disturbanceofconsciousness(i.e.,reducedclarityofawarenessabouttheenvironment)withreducedabilitytofocus,sustain,orshiftattention.B.Achangeincognition(e.g.,memorydeficit,disorientation,languagedisturbance)ordevelopmentofaperceptualdisturbancethatisnotbetteraccountedforbyapreexisting,established,orevolvingdementia.C.Thedisturbancedevelopsoverashortperiodoftime(usuallyhourstodays)andtendstofluctuateduringthecourseofaday.D.Evidencefromthehistory,physicalexamination,orlaboratoryfindingsindicatethatthedisturbanceiscausedbydirectphysiologicconsequencesofageneralmedicalcondition.ReprintedwithpermissionfromDiagnosticandstatisticalmanualofmentaldisorders:DSM-IV-TR.Washington,D.C.,AmericanPsychiatricAssociation,2000:143.Copyright2000,AmericanPsychiatricAssociation.AcuteOnset/FluctuatingLevelsofConsciousnessJumptosection+ Abstract AcuteOnset/FluctuatingLevelsofConsciousnessSubtypesofDeliriumScreeningToolsIndicationsofUnderlyingMedicalConditionsDifferentiatingDeliriumfromPrimaryPsychiatricDisorderRiskFactorsManagementReferencesDeliriumischaracterizedbyanacutechange(usuallyoverhourstodays)inmentalstatus.Patientsdemonstratefluctuatinglevelsofconsciousnessthattheyoftenmanifestbyperiodicallyfallingasleepduringaninterview.Thisfluctuationinconsciousnesscanresultinconflictingreportsfromvariouscaregiversaboutthepatient’smentalstate.Fluctuationsincognitiveskills,includingmemory,language,andorganization,arealsocommon.ATTENTIONIMPAIRMENTPatientswithdeliriumdemonstrateattentiondifficulties.Theymaynotrememberinstructionsandmayaskthatdirectionsandquestionsberepeated.Usefulscreeningmethodstoidentifyattentionproblemsincludeaskingpatientstospellawordbackwardsorperform“serial7s”(countingbackwardfrom100bysevens).MEMORYIMPAIRMENTANDDISORIENTATIONMemorydeficits,especiallywhererecenteventsareconcerned(e.g.,thereasonforhospitalizationorforcarebeinggivenbynursingstaff),arealsoprominentinpatientswithdelirium.Patientsmayreportnotbeingbathedorbeddingnotbeingchangedwhen,infact,theseeventsoccurredearlierintheday.Disorientationtodate,place,andsituationiscommon.However,thelattercangounrecognizedifpatientsarenotdirectlyaskedfortheinformation.Forexample,hospitalstaffandfamilymembersmayassumethatapatientisfullyorientedonlytobesurprisedwhenthepatientinsiststhatheorsheisathomeandthatthedateis10yearsearlier.AGITATIONPatientswithdeliriummaybecomeagitatedasaresultofthedisorientationandconfusiontheyareexperiencing.Forexample,apatientwhoisdisorientedmaythinkheorsheisathomeinsteadofinahospital,andnursingstaffmaybemistakenforintrudersinthehome.Consequently,thispatientmaynotcomplywithbedoractivityrestrictionsandmaytrytoclimboverthebedrailstogetoutofbed.Likewise,intravenous(IV)andoxygentubingmaynotberecognizedassuch,andthepatientmayremovethem.APATHYANDWITHDRAWALPatientswithdeliriummaypresentwithapathyandwithdrawal.Theymayappeartobedepressedbecauseofbluntedaffect,decreasedappetite,decreasedmotivation,anddisruptedsleeppatterns.SLEEPDISTURBANCESleepdisturbancesarecommoninpatientswithdelirium.Theymayperiodicallyfallasleepduringthedayandthenbeawakeforseveralhoursduringthenight.Thispattern,combinedwithconfusion,disorientation,anddecreasednighttimeenvironmentalcues,cancreateanespeciallyhazardoussituationinpatientswhoareatriskforfallingandpullingoutanIV,Foleycatheter,ornasogastrictubing.EMOTIONALLABILITYPatientswithdeliriummaydisplayawiderangeofemotions,includinganxiety,sadnessortearfulness,andeuphoria.Theymayhavemorethanoneoftheseemotionsduringthecourseofdelirium.PERCEPTUALDISTURBANCESDisturbancesinrealitytestingmanifestedbyvisualandauditoryhallucinationsanddelusionsmaybepresent.Delusionsassociatedwithdeliriumarelikelytoberelatedtodisorientationandmemoryimpairment,andfluctuatewiththesesymptoms.NEUROLOGICSIGNSSeveralneurologicsignsandsymptomsmaybepresentindeliriumregardlessofcause.Theyincludeunsteadygait;tremor;asterixis;myoclonus,paratonia(e.g.,gegenhalten)ofthelimbsandespeciallyoftheneck;difficultyreadingandwriting;andvisuoconstructionproblems,suchascopyingdesignsandfindingwords.SubtypesofDeliriumJumptosection+ Abstract AcuteOnset/FluctuatingLevelsofConsciousnessSubtypesofDeliriumScreeningToolsIndicationsofUnderlyingMedicalConditionsDifferentiatingDeliriumfromPrimaryPsychiatricDisorderRiskFactorsManagementReferencesThethreesubtypesofdeliriumarehyperactive,hypoactive,andmixed.Patientswiththehyperactivesubtypemaybeagitated,disoriented,anddelusional,andmayexperiencehallucinations.Thispresentationcanbeconfusedwiththatofschizophrenia,agitateddementia,orapsychoticdisorder.Patientswiththehypoactivesubtypeofdeliriumaresubdued,quietlyconfused,disoriented,andapathetic.Deliriuminthesepatientsmaygounrecognizedorbeconfusedwithdepressionordementia.Themixedsubtypeischaracterizedbyfluctuationsbetweenthehyperactiveandhypoactivesubtypes.ScreeningToolsJumptosection+ Abstract AcuteOnset/FluctuatingLevelsofConsciousnessSubtypesofDeliriumScreeningToolsIndicationsofUnderlyingMedicalConditionsDifferentiatingDeliriumfromPrimaryPsychiatricDisorderRiskFactorsManagementReferencesSeveralscreeningtoolsareavailabletoaidinidentifyingdelirium.TheFolsteinMini-MentalStateExamination(MMSE)2isfamiliartomostphysicians.Itscreensfordeficitsinorientation,attention,memory,language,andvisuoconstructionabilities.AdministeringtheMMSEseveraltimesduringthecourseofdeliriumcanbeawaytoassessimprovement.ComparisonwithanMMSEperformedbeforetheonsetofthedeliriumisideal.AnotherscreeningtoolistheConfusionAssessmentMethod.3TheDeliriumRatingScale(DRS)4andtheMemorialDeliriumAssessmentScale(MDAS)5measuretheseverityofdelirium.IndicationsofUnderlyingMedicalConditionsJumptosection+ Abstract AcuteOnset/FluctuatingLevelsofConsciousnessSubtypesofDeliriumScreeningToolsIndicationsofUnderlyingMedicalConditionsDifferentiatingDeliriumfromPrimaryPsychiatricDisorderRiskFactorsManagementReferencesRecognizingdeliriumisimportantbecauseitisanindicationofanunderlyingmedicalconditionthatshouldbeidentifiedandtreated.Theunderlyingetiologyshouldbeaggressivelysoughtafter.Deliriumcanbecausedbyamedicalemergencyorasubacute,chronicmedicalcondition(Table2).6Prescriptiondrugs,illicitdrugs,andtoxicsubstancescanalsocausedelirium.Theunderlyingmedicalconditionisnotalwaysreadilyidentifiable,andmorethanoneetiologyisoftenresponsiblefordelirium.Infact,inalmostonehalfofelderlypatientswithdelirium,twoormoreunderlyingconditionsareresponsibleforthedelirium.7TABLE2DifferentialDiagnosisofDeliriumUsingtheMnemonic‘IWATCHDEATH’Therightsholderdidnotgrantrightstoreproducethisiteminelectronicmedia.Forthemissingitem,seetheoriginalprintversionofthispublication.DifferentiatingDeliriumfromPrimaryPsychiatricDisorderJumptosection+ Abstract AcuteOnset/FluctuatingLevelsofConsciousnessSubtypesofDeliriumScreeningToolsIndicationsofUnderlyingMedicalConditionsDifferentiatingDeliriumfromPrimaryPsychiatricDisorderRiskFactorsManagementReferencesCertainsignsandsymptomscanhelpphysiciansdistinguishbetweendeliriumandapreexistingpsychiatricdisorder.Forexample,visualhallucinationsareanindicatorofanunderlyingmetabolicdisturbanceoradverseeffectofmedicationorsubstanceabuse.Whilevisualhallucinationscanoccurinpatientswithprimarypsychiatricillnessessuchasschizophrenia,theyaremuchlesscommonthanauditoryhallucinations.Inprimarypsychiatricdisorders,visualhallucinationswouldbeassociatedwithother,morecharacteristicsignsandsymptomsofthedisorders.Visualhallucinationsthatoccurinpatientswithdeliriumcanbeformed(e.g.,people,animals)orunformed(e.g.,spots,flashesoflight).Electroencephalography(EEG)canbeusefulindifferentiatingdeliriumfromotherconditions.Inpatientswithdelirium,theEEGshowsadiffuseslowingofthebackgroundrhythm.Anexceptionispatientswithdeliriumtremens,wheretheEEGshowsfastactivity.EEGsarealsousefulindetectingictalandpostictalseizureactivity,aswellasnonconvulsivestatusepilepticus,allofwhichcanpresentasdelirium.AbnormalEEGreadingswouldnotbeexpectedinpatientswithpsychoticdisordersordepression.However,slowingmayoccurinpatientswithdementia.Finally,theacuteonsetandfluctuatingnatureofdeliriumarekeyfeaturesindistinguishingitfromprimarypsychiatricdisorders.Patientsareoftenunabletoprovideanadequatehistory.Itisimportanttointerviewfamilymembersandcaregiverstodeterminethetimeofonsetofsymptomsandotherpertinentmedicalandpsychiatricinformation,includingareviewofmedicationsandahistoryofsubstanceabuse.Itisequallyimportanttoknowhowpatientsarecurrentlydifferentfromtheirnormalcognitivestate.Psychiatricsymptomsthatariseinpersons50yearsandolderwithoutapriorpsychiatrichistoryorthedevelopmentofnewsymptomsinpatientswithpreexistingpsychiatricillnessshouldpromptathoroughmedicalwork-up.Table3providesalistofindicatorssuggestingdelirium.Table4listssomedistinguishingcharacteristicsofdelirium,dementia,psychosis,anddepression.View/PrintTableTABLE3IndicatorsSuggestingDeliriumAcutechangeinmentalstatusPresenceofmedicalillnessVisualhallucinationsFluctuatinglevelsofconsciousnessAcuteonsetofpsychiatricsymptomswithoutpriorhistoryofpsychiatricillnessAcuteonsetofnewordifferentpsychiatricsymptomswithhistoryofpriorpsychiatricillnessPatientdescribedas“confused”or“disoriented”DiffuseslowwavesorepileptiformdischargesonelectroencephalogramTABLE3IndicatorsSuggestingDeliriumAcutechangeinmentalstatusPresenceofmedicalillnessVisualhallucinationsFluctuatinglevelsofconsciousnessAcuteonsetofpsychiatricsymptomswithoutpriorhistoryofpsychiatricillnessAcuteonsetofnewordifferentpsychiatricsymptomswithhistoryofpriorpsychiatricillnessPatientdescribedas“confused”or“disoriented”DiffuseslowwavesorepileptiformdischargesonelectroencephalogramView/PrintTableTABLE4DistinguishingCharacteristicsofDelirium,Dementia,PsychoticDisorders,andDepressionDisorderDistinguishingfeatureAssociatedsymptomsCourseDeliriumFluctuatinglevelsofconsciousnesswithdecreasedattentionDisorientation,visualhallucinations,agitation,apathy,withdrawal,impairmentinmemoryandattentionAcuteonset;mostcasesremitwithcorrectionofunderlyingmedicalconditionDementiaMemoryimpairmentDisorientation,agitationChronic,slowonset,progressivePsychoticdisordersDeficitsinrealitytestingSocialwithdrawal,apathyUsuallyslowonsetwithprodromalsyndrome;chronicwithexacerbationsDepressionSadness,lossofinterestandpleasureinusualactivitiesDisturbancesofsleep,appetite,concentration,andenergy;feelingsofhopelessnessandworthlessness;thoughtsofsuicideSingleepisodeorrecurrentepisodes;maybechronicTABLE4DistinguishingCharacteristicsofDelirium,Dementia,PsychoticDisorders,andDepressionDisorderDistinguishingfeatureAssociatedsymptomsCourseDeliriumFluctuatinglevelsofconsciousnesswithdecreasedattentionDisorientation,visualhallucinations,agitation,apathy,withdrawal,impairmentinmemoryandattentionAcuteonset;mostcasesremitwithcorrectionofunderlyingmedicalconditionDementiaMemoryimpairmentDisorientation,agitationChronic,slowonset,progressivePsychoticdisordersDeficitsinrealitytestingSocialwithdrawal,apathyUsuallyslowonsetwithprodromalsyndrome;chronicwithexacerbationsDepressionSadness,lossofinterestandpleasureinusualactivitiesDisturbancesofsleep,appetite,concentration,andenergy;feelingsofhopelessnessandworthlessness;thoughtsofsuicideSingleepisodeorrecurrentepisodes;maybechronicRiskFactorsJumptosection+ Abstract AcuteOnset/FluctuatingLevelsofConsciousnessSubtypesofDeliriumScreeningToolsIndicationsofUnderlyingMedicalConditionsDifferentiatingDeliriumfromPrimaryPsychiatricDisorderRiskFactorsManagementReferencesDeliriumaffects10to30percentofhospitalizedpatientswhoaremedicallyill.8Theprevalenceisevenhigherincertainsubgroups.Forexample,25percentofhospitalizedpatientswithcancer,30to40percentofhospitalizedpatientswithhumanimmunodeficiencyvirus(HIV)infection,andmorethan50percentofpostoperativepatientsdevelopdeliriumduringhospitalization.9–11Amongnursinghomeresidentsolderthan75,upto60percentmayhavedeliriumatanytime.12 Table5liststhecharacteristicsofpatientswhoareatincreasedriskfordeliriumandsomemedicalconditionsthatincreaseapatient’sriskfordevelopingdelirium.Recognizingdementiaasariskfactorfordeliriumcanhelpphysiciansavoidattributingtheconfusionandagitationassociatedwithdeliriumtopreexistingdementia,whichcanleadtoafailuretosearchforunderlyingmedicalconditionsortodiscontinuemedicationsthatmaybecausingthedelirium.View/PrintTableTABLE5RiskFactorsforDeliriumPatientcharacteristicsHospitalizedelderlyMultiplemedicalconditionsMultiplemedicationsTerminallyillChildrenSensory(hearingorvisual)deprivationSleepdeprivedMedicalconditionsDementiaPostsurgicalstatusCardiacHipTransplantBurnsAbruptdiscontinuationofalcoholordrugsMalnourishmentChronichepaticdiseaseDialysisParkinson’sdiseaseHIVinfectionPoststrokestatusHIV=humanimmunodeficiencyvirus.TABLE5RiskFactorsforDeliriumPatientcharacteristicsHospitalizedelderlyMultiplemedicalconditionsMultiplemedicationsTerminallyillChildrenSensory(hearingorvisual)deprivationSleepdeprivedMedicalconditionsDementiaPostsurgicalstatusCardiacHipTransplantBurnsAbruptdiscontinuationofalcoholordrugsMalnourishmentChronichepaticdiseaseDialysisParkinson’sdiseaseHIVinfectionPoststrokestatusHIV=humanimmunodeficiencyvirus.ManagementJumptosection+ Abstract AcuteOnset/FluctuatingLevelsofConsciousnessSubtypesofDeliriumScreeningToolsIndicationsofUnderlyingMedicalConditionsDifferentiatingDeliriumfromPrimaryPsychiatricDisorderRiskFactorsManagementReferencesIDENTIFYINGUNDERLYINGMEDICALCONDITIONSThedefinitivetreatmentfordeliriumistocorrecttheunderlyingmedicalconditioncausingthedisorder.Theinitialstepsinmanagingpatientswithdeliriumaretoconductacarefulreviewofthemedicalhistory,physicalexaminationfindings,laboratoryevaluations,andanydrugsthepatientisusing,includingover-the-counteragents,illicitdrugs,andalcohol.Informationfrompatients’currentandpastmedicalhistory,aswellasthephysicalexamination,shouldguidetheinitialwork-up.Oftentheetiologywillbefairlyobviousfromthehistoryandbasiclaboratorytests.13 Table66,14outlinesaplanforassessingpatientswithdelirium.TABLE6AssessmentofPatientswithDeliriumTherightsholderdidnotgrantrightstoreproducethisiteminelectronicmedia.Forthemissingitem,seetheoriginalprintversionofthispublication.SYMPTOMATICTREATMENTDuringthesearchforanunderlyingmedicalcondition,symptomatictreatmentfordeliriummayincludetheuseofantipsychoticdrugstocontrolagitationandhallucinations,andtoclearthesensorium(i.e.,improveattentionabilitiesandleveloforientation).Haloperidol(Haldol)hasbeenstudiedmostofteninthesymptomaticmanagementofdelirium,8butrisperidone(Risperdal)15,16andolanzapine(Zyprexa),17whicharenewer,atypicalantipsychotics,havebeenthesubjectsofafewcasereports.Twosmallstudies18,19witholanzapinesuggestedthatthisdrugmightbeausefulalternativeinthetreatmentofdelirium.Inmostadultpatientswithdeliriumofmoderateseverity,haloperidoltherapycanbeinitiatedat1to2mgtwicedaily,repeatedeveryfourhoursasneeded,andcanbeadministeredviaIV,oral,orintramuscularroutes.TheIVroutehasbeenshowntoproducealowerincidenceofextrapyramidalsideeffects20;however,itdoescarryariskforthedevelopmentoftorsadesdepointes.21,22Preferably,patientsreceivingIVhaloperidolshouldbeonacardiacmonitor.QTcprolongationgreaterthan450msecormorethan25percentabovebaselineshouldpromptthephysiciantoconsiderdiscontinuinghaloperidoltherapy,oracardiologyconsultationshouldbeobtained.8Elderlypatientsshouldbestartedatlowerdrugdosages.Inthesepatients,haloperidoltherapycanbestartedat0.25to1.0mgtwicedailyandrepeatedeveryfourhours,asneeded.8Risperidonetherapycanbeinitiatedatadosageof0.5mgtwicedailyandincreasedgraduallyifnecessary.Inallpatients,responsetoantipsychoticsandtheamountofas-neededmedicationusedshouldbemonitoredatleastevery24hours.Ifas-neededmedicationisnecessaryonaregularbasis,theamountofscheduledantipsychoticshouldbeincreased.Whenpatients’cognitivestatesstabilize,antipsychoticsshouldbecontinuedoverthenextfewdays,thentaperedanddiscontinued.Physiciansshouldnotautomaticallydiscontinueantipsychoticsonthefirstdaythepatient’smentalstatusshowsimprovement,becausetheimprovementmayjustbeanormalfluctuationinthedelirium.Gradualtaperingthatendsindiscontinuationallowstimetoassesspatients,toensurethatthedeliriumhasresolvedandavoidrapidreboundofsymptoms.ENVIRONMENTALINTERVENTIONSEnvironmentalinterventionsthatcanhelpinmanagingpatientswithdeliriumarelistedinTable7.23Assigningpatientstoaroomnearthenursingstationwillallowforclosermonitoring.Thepresenceofafamilymemberorclosefriendcanalsobehelpful.Inmoreseverecases,theuseof24-hour,one-on-onesupervisionmaybenecessarytomonitorthepatientandassistincontrollingagitation.Frequentreorientationbynursingstaffandfamilymembersisimportant.Patientsshouldberemindedofthemonth,year,dayoftheweek,timeofday,andreasonforhospitalization.Patientsshouldalsoberemindedofthenameofthehospital,city,andstate.Acalendar,clock,andfamilypicturesdisplayedwithinpatients’viewcanbebeneficial.View/PrintTableTABLE7EnvironmentalInterventionsinTreatingPatientswithDeliriumProvidesupportandorientationCommunicateclearlyandconcisely;giverepeatedverbalremindersoftheday,time,location,andidentityofkeypersons,suchasmembersofthetreatmentteamandrelatives.Provideclearsignpoststopatient’slocation,includingaclock,calendar,andchartwiththeday’sschedule.Placefamiliarobjectsfrompatient’shomeintheroom.Ensureconsistencyinstaff(e.g.,akeynurse).Usetelevisionorradioforrelaxationandtohelpthepatientmaintaincontactwiththeoutsideworld.Involvefamilymembersandcaregiverstoencouragefeelingsofsecurityandorientation.ProvideanunambiguousenvironmentSimplifycareareabyremovingunnecessaryobjects;allowadequatespacebetweenbeds.Considerusingprivateroomtoaidrestandavoidextremesofsensoryexperience.Avoidusingmedicaljargoninpatient’spresencebecauseitmayencourageparanoia.Ensurethatlightingisadequate;providea40-to60-wattnightlighttoreducemisperceptions.Controlsourcesofexcessnoise(e.g.,staff,equipment,visitors);aimforfewerthan45dBduringthedayandfewerthan20dBduringthenight.Maintainroomtemperaturebetween21.1C(69.98F)and23.8C(74.8F)MaintainingcompetencyIdentifyandcorrectsensoryimpairments;ensurepatientshavetheirglasses,hearingaids,anddentures.Considerwhetherinterpreterisneeded.Encourageself-careandparticipationintreatment(e.g.,askpatientforfeedbackonpain).Arrangetreatmentstoallowmaximumperiodsofuninterruptedsleep.Maintainactivitylevels:ambulatorypatientsshouldwalkthreetimesdaily;nonambulatorypatientsshouldundergofullrangeofmovementexercisefor15minutesthreetimesdaily.AdaptedwithpermissionfromMeagherDJ.Delirium:optimisingmanagement.BMJ2001;322:146.TABLE7EnvironmentalInterventionsinTreatingPatientswithDeliriumProvidesupportandorientationCommunicateclearlyandconcisely;giverepeatedverbalremindersoftheday,time,location,andidentityofkeypersons,suchasmembersofthetreatmentteamandrelatives.Provideclearsignpoststopatient’slocation,includingaclock,calendar,andchartwiththeday’sschedule.Placefamiliarobjectsfrompatient’shomeintheroom.Ensureconsistencyinstaff(e.g.,akeynurse).Usetelevisionorradioforrelaxationandtohelpthepatientmaintaincontactwiththeoutsideworld.Involvefamilymembersandcaregiverstoencouragefeelingsofsecurityandorientation.ProvideanunambiguousenvironmentSimplifycareareabyremovingunnecessaryobjects;allowadequatespacebetweenbeds.Considerusingprivateroomtoaidrestandavoidextremesofsensoryexperience.Avoidusingmedicaljargoninpatient’spresencebecauseitmayencourageparanoia.Ensurethatlightingisadequate;providea40-to60-wattnightlighttoreducemisperceptions.Controlsourcesofexcessnoise(e.g.,staff,equipment,visitors);aimforfewerthan45dBduringthedayandfewerthan20dBduringthenight.Maintainroomtemperaturebetween21.1C(69.98F)and23.8C(74.8F)MaintainingcompetencyIdentifyandcorrectsensoryimpairments;ensurepatientshavetheirglasses,hearingaids,anddentures.Considerwhetherinterpreterisneeded.Encourageself-careandparticipationintreatment(e.g.,askpatientforfeedbackonpain).Arrangetreatmentstoallowmaximumperiodsofuninterruptedsleep.Maintainactivitylevels:ambulatorypatientsshouldwalkthreetimesdaily;nonambulatorypatientsshouldundergofullrangeofmovementexercisefor15minutesthreetimesdaily.AdaptedwithpermissionfromMeagherDJ.Delirium:optimisingmanagement.BMJ2001;322:146.Understimulationresultingfromabsenceofcuesaboutthetimeofdayandthesituationshouldbeavoided,butoverstimulationshouldalsobeavoided.Theactivity,light,andnoise(includingthatfrombeepers)inandaroundthepatients’roomsshouldbemonitored.Frequentcheckingofvitalsignsduringthenightshouldbeavoidedunlessthenecessityisclearlyindicated,becausefrequentwakingcanleadtosleepdeprivation,whichmayworsendelirium.24Theuseofphysicalrestraintsshouldbeavoided,ifpossible.Physicalrestraintcanincreaseagitationandtheriskforinjuryinpatientswhoarecognitivelyimpaired.However,ifothermeasurestocontrolapatient’sbehaviorareineffectiveanditseemslikelythatthepatient,ifunrestrained,maycausepersonalinjuryorinjureothers,restraintscanbeusedwithcaution.Patientswhoarerestrainedshouldbemonitoredclosely,andrestraintsshouldbediscontinuedassoonaspossible.Physiciansshouldbeawareofhospitalpoliciesandotherregulationsregardingtheuseofphysicalrestraints.25Deliriumcanbeafrighteningexperienceforpatientsandfamilymembers.Patientsmayfearthattheyarelosingtheirminds.Educatingpatientsandfamilymembersaboutdeliriumanditsassociationwithunderlyingmedicalconditionsisimportant.Unlessthereisreasontobelievethatapatienthasexperiencedpermanentlossofcognitivefunction,thepatientandfamilymembersshouldbereassuredthatthesymptomsaretemporaryandshouldresolve.Neurologicconsultationcanhelpestablishadifferentialdiagnosisinpatientswithdelirium.Psychiatricconsultationcanaidindistinguishingdeliriumfromaprimarypsychiatricdisorderandinmanagingthebehaviordisturbancesassociatedwithdelirium.COURSEANDPROGNOSISConsiderablemorbidityandmortalityareassociatedwithdelirium.Patientswithdeliriumhavelongerhospitalstaysandmoremedicalcomplications,suchaspneumoniaandpressureulcers.Mortalityisalsohigherinpatientswithdelirium,probablyasaresultofmoresevereunderlyingmedicalpathology.Themortalityrateamongelderlyhospitalizedpatientswithdeliriumisestimatedtorangefrom22to76percent.8Thecourseofdeliriumcanlastfromseveralhourstoseveralmonths.Throughappropriateidentificationandcorrectionoftheunderlyingetiology,mostpatientsexperiencecompleteresolutionofdelirium,althoughfullrecoveryofmentalfunctionmaylagbehindcorrectedlaboratoryvaluesbyseveraldays.Withouttreatment,however,progressiontostupor,coma,ordeathcanoccur.PatientswhoareelderlyandthosewhohaveHIVinfectionarelesslikelytofullyrecover.26,27Readthefullarticle.Getimmediateaccess,anytime,anywhere.Chooseasinglearticle,issue,orfull-accesssubscription.Earnupto6CMEcreditsperissue.Alreadyamember/subscriber? Login>> PurchaseAccess:SeeMyOptionscloseAlreadyamemberorsubscriber?Login BestValue!GetFullAccessFrom$145SubscribeIncludes:Immediate,unlimitedaccesstoallAFPcontentMorethan130CMEcreditsperyearAccessthejournalthroughtheAAFPappPrintdeliveryoption AccessThisIssue$59.95 Includes:Immediateaccesstothisissue CMEcreditsinthisissue  AccessThisArticle$25.95  Includes:ImmediateaccesstothisarticleInterestedinAAFPmembership?Learnmore     Toseethefullarticle,loginorpurchaseaccess.TheAuthorshowallauthorinfoONDRIAC.GLEASON,M.D.,isassistantprofessorofpsychiatryanddirectorofpsychiatryresidencytrainingattheUniversityofOklahomaCollegeofMedicine,Tulsa.SheisalsoastaffpsychiatristatSaintFrancisHospital,Tulsa,Okla.Dr.GleasonearnedhermedicaldegreefromtheUniversityofNebraskaCollegeofMedicine,Omaha,andcompletedaresidencyinpsychiatryattheUniversityofIowaHospitalsandClinics,IowaCity....AddresscorrespondencetoOndriaC.Gleason,M.D.,UniversityofOklahomaCollegeofMedicineatTulsa,DepartmentofPsychiatry,4502E.41stSt.,Tulsa,OK74135-2512(e-mail:[email protected]).Reprintsarenotavailablefromtheauthor.Theauthorindicatesthatshedoesnothaveanyconflictsofinterest.Sourcesoffunding:nonereported.REFERENCESshowallreferences1.Diagnosticandstatisticalmanualofmentaldisorders:DSM-IV-TR.Washington,D.C.,AmericanPsychiatricAssociation,2000....2.FolsteinMF, FolsteinSE, McHughPR. “Mini-mentalstate”.Apracticalmethodforgradingthecognitivestateofpatientsfortheclinician”.JPsychiatrRes. 1975;12:189–98.3.InouyeSK, vanDyckCH, AlessiCA, BalkinS, SiegalAP, HorwitzRI. 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Decreasedextrapyramidalsymptomswithintravenoushaloperidol.JClinPsychiatry. 1987;48:278–80.21.WiltJL, MinnemaAM, JohnsonRF, RosenblumAM. Torsadesdepointesassociatedwiththeuseofintravenoushaloperidol.AnnInternMed. 1993;119:391–4.22.SharmaND, RosmanHS, PadhiID, TisdaleJE. Torsadesdepointesassociatedwithintravenoushaloperidolincriticallyillpatients.AmJCardiol. 1998;81:238–40.23.MeagherDJ. Delirium:optimisingmanagement.BMJ. 2001;322:144–9.24.InouyeSK, BogardusST, CharpentierPA, Leo-SummersL, AcamporaD, HolfordTR, etal. Amulticomponentinterventiontopreventdeliriuminhospitalizedolderpatients.NEnglJMed. 1999;340:669–76.25.HCFAoverrulesJCAHOrestraintstandard.. HospPeerRev. 2000;25:88–9.26.RockwoodK. Theoccurrenceanddurationsofsymptomsinelderlypatientswithdelirium.JGerontol. 1993;48:M162–6.27.FernandezF, LevyJK, MansellPW. ManagementofdeliriuminterminallyillAIDSpatients.IntJPsychiatryMed. 1989;19:165–72.Add/viewcommentsHidecomments    Copyright©2003bytheAmericanAcademyofFamilyPhysicians. ThiscontentisownedbytheAAFP.Apersonviewingitonlinemaymakeoneprintoutofthematerialandmayusethatprintoutonlyforhisorherpersonal,non-commercialreference.Thismaterialmaynototherwisebedownloaded,copied,printed,stored,transmittedorreproducedinanymedium,whethernowknownorlaterinvented,exceptasauthorizedinwritingbytheAAFP.Contact [email protected]/orpermissionrequests. PDF PRINT COMMENTS Wanttousethisarticleelsewhere?GetPermissions Advertisement MoreinAFP RelatedContent Delirium MoreinPubmed Citation RelatedArticles MOSTRECENTISSUE Oct2021 AccessthelatestissueofAmericanFamilyPhysician ReadtheIssue EmailAlerts Don'tmissasingleissue.SignupforthefreeAFPemailtableofcontents. SignUpNow NavigatethisArticle ContinuereadingfromMarch1,2003 Previous:DiagnosingNightSweats Next:ChildhoodConstipation Viewthefulltableofcontents>> Home /Journals /afp /Vol.67/No.5(March1,2003) / Delirium