Confusion, Delirium and
Samira Khazravan, M.D.
Department of Geriatrics
Mary Immaculate Hospital
“Acute Confusional State”
Word delirium is derived from Latin term meaning "off
Not a disease but a syndrome with multiple causes that
result in a similar constellation of symptoms.
The clinical hallmarks are ed attention span & a
waxing & waning type of confusion.
A transient, usually reversible, impairment of
consciousness with a ed ability to focus, sustain or
Should be treated as a medical emergency (early
diagnosis & resolution of symptoms are correlated with
the most favorable outcomes).
CRITERIA FOR DIAGNOSING
A ∆ in cognition or development of a perceptual
disturbance that is not better accounted for by a
preexisting, established or evolving Dementia.
Develops over a short period of time & tends to
fluctuate during the course of the day.
There is evidence that the disturbance is caused by
a medical condition, intoxication or med use.
There is no clear evidence of any underlying
14-56% of hospitalized elderly patients.
Delirium is present in 10-22% of elderly patients at the time of
admission, with an additional 10-30% of cases developing after
found in 40% of patients admitted to ICU.
Extremely common among nursing home residents.
Can occur at any age.
MC in pts who are elderly & have compromised mental status.
ed risk in pts w/dementia (2/3 of cases of delirium occur in pts
Delirium due to physical illness is MC among very young & those
older than 60 years.
Delirium due to drug & alcohol intoxication or withdrawal is most
frequent in persons aged mid teens to the late 30s.
Functional impairment in ADLs
Medical co morbidity
History of alcohol abuse
♀ > or < ♂
MC whites than in other races
Sensory impairment – decreased vision & hearing
Acute cardiac/pulmonary events
10-fold risk of death.
3-5-fold increase risk of nosocomial complications.
Poor functional recovery & ed risk of death up to 2 years
Some causes of delirium (Delirium Tremens,
Severe Hypoglycemia, CNS infx, Heat stroke, Thyroid
storm) may be fatal or result in severe morbidity if
unrecognized & untreated.
With some exceptions, such as OD of TCAs, drug
intoxications generally resolve fully with supportive care.
Exact pathophysiological mechanisms unclear.
The main hypothesis is reversible impairment of cerebral
oxidative metabolism & multiple NT abnormalities
(Acetylcholine, Dopamine, Serotonin, GABA)
– Interruption of BBB
– Inflammatory mechanism [cytokines (interleukin-1 &
6) are ed following infx, inflammation, toxic insults,
head trauma & ischemia]
– Stress rxn mechanism [psychosocial stress and sleep
deprivation facilitate the onset of delirium].
ETIOLOGY Intracranial causes
– Dementia w/Lewy bodies [only dementia that features
transient episodes of impaired consciousness as a typical
-No other dementias feature impairment of consciousness
unless complicated by a delirium (i.e. 2° to infx, anoxia,
ETIOLOGY Intracranial causes
Head injury (esp. Concussion)
– Alcohol (Delirium tremens, Wernicke-Korsakoff
– Sedative-Hypnotic use/abuse.
Heavy metals (Lead, Mercury, Manganese)
ETIOLOGY Drugs (ingestion or
– Amphotericin B – Dopaminergic agents
– Anticholinergics – Disulfiram
– Anticonvulsants – Digoxin
– Antihypertensive drugs [-
– Antiparkinsonian drugs
– Antipsychotics – Sedatives (barbiturates
– Cannabis & benzodiazepines)
– H2 Blocker (Cimetidine) – TCAs
ETIOLOGY Intracranial causes
– Meningitis & Encephalitis (Bacterial, Viral, Fungal,
Parasitic or Tuberculosis organisms)
– Cerebral thrombosis or Embolism
– Intracranial or SAH
– HTNive Encephalopathy
Vasculitis (e.g. From SLE)
ETIOLOGY Metabolic & endocrine
– Electrolyte – Thyrotoxicosis
disturbances (Na+, – & thyroidism
– Acid-Base D/o parathyroidism
– Renal Failure & – &
– Hepatic (Cushing’s syndrome,
encephalopathy Addison’s disease)
– Hypoglycemia (DM) – Pheochromocytoma
– DKA – Hypopituitarism
– Insulinoma – Wilson’s disease
– Thiamine (Wernicke’s encephalopathy)
– Vitamin B12 (Pernicious Anemia)
– Vitamin B1 (Beriberi)
– Folic acid
– Respiratory failure (Hypoxia/Hypercarbia)
– Heart failure
MI, A. Fib
Neoplasms (1 or metastatic lesions of
CNS; CA induced HyperCa2+)
– Alzheimer’s, Pick’s Dz, Multiple Sclerosis,
Parkinsonism, Huntington’s chorea, Normal
Major causes of delirium – HIDE
– Electrolyte disturbances
SIGNS & SYMPTOMS
Usually acute onset
Fluctuating levels of consciousness (impairment
usually least in AM)
Perceptual disturbances (hallucinations or
– Reduced awareness of environment clouding of
– Reduced ability to sustain attention (easily
SIGNS & SYMPTOMS
Impaired cognitive function
– Impaired STM (1° memory) & recent memory.
– Disoriented to time & often place [orientation
to self seldom lost].
– Language abnormalities [rambling, incoherent
speech & impaired ability to understand]
SIGNS & SYMPTOMS
Perceptual & thought disturbance
– Ranging from misinterpretations (e.g. A door
slamming is mistaken for an explosion)
illusions (e.g. A crack in the wall is perceived
as a snake) hallucinations (especially visual)
– Patients may be hyper or hypoactive or
fluctuate from one to the other
– May also have an enhanced startle reaction
SIGNS & SYMPTOMS
Sleep-wake cycle disturbance
– Daytime drowsiness night-time hyperactivity
complete reversal of normal cycle
– Nightmares of delirious patients may continue as
hallucinations after awakening
Mood disturbance (Emotional Liability)
– Depression, euphoria, anxiety, anger, fear & apathy
– Lack of initiative, impaired impulse control, inability
to reason thru problems, confabulation
A physical illness should always be ruled
out whenever a patient presents with
prominent visual hallucinations because
patients with schizophrenia & other
functional psychotic disorders usually
experience auditory hallucinations.
Primary psychiatric illnesses – Depression, Mania,
Sundowning (mild to mod delirium @ night—MC in pts
w/preexisting dementia & may be precipitated by
hospitalization, drugs & sensory deprivation)disturbance
in circadian rhythm.
Focal syndromes – Wernicke’s aphasia, Anton’s
syndrome & Bi-frontal lesions.
Delirium often is unrecognized or
misdiagnosed & commonly is mistaken for
dementia, depression, mania, an acute
schizophrenic reaction or part of old age
(patients who are elderly are expected to
become confused in the hospital).
FEATURE DELIRIUM DEMENTIA
ONSET Acute Gradual
DURATION Hours – Months – years
COURSE Fluctuating Progressive
CONSCIOUSNESS Impaired Normal
PERCEPTUAL Common Occurs in late
SLEEP-WAKE CYCLE Disrupted Usually normal
PROGNOSIS Potentially Not reversible
PRIMARILY AFFECTS Attention Memory
MEDICAL Yes No
Under-recognition is a major problem – nurses recognize &
document <50%; DSM-IV criteria is precise but difficult to apply.
History & Physical – focus on time course of cognitive changes,
especially their association w/other symptoms or events; Note
recently started meds, overdose, alcohol use, previous history,
concurrent medical problems, signs of organ failure & infx (occult
UTI is common in elderly), general medical evaluation, neurologic
& mental status examination.
Remember: Delirium is not a final diagnosis: this syndrome
indicates the presence of a very serious medical condition that
should be managed on medical not psychiatric, ward.
Any pt who presents w/AMS needs a complete PE, w/particular attn
– General appearance (unkempt, tattooed &/or malnourished) may
suggest the possibility of drug or alcohol abuse)
– Vital signs
– Hydration status
– Evidence of physical trauma
– Evidence of neurological signs
The delirious or obtunded patient should be evaluated for Pupillary,
Fundoscopic & extraocular abnormalities; nuchal rigidity; thyroid
enlargement & heart murmurs or rhythm disturbances.
Other clues to etiology on PE:
– A pulmonary exam wheezing, rales or absent breath
– An abdominal exam Hepato/Splenomegaly
– A cutaneous exam rashes, icterus, petechiae,
ecchymosis, track marks or Cellulitis (often hidden under
clothing, particularly pants & socks; checking these areas
in pts with diabetes is critical; any serious infx can lead
to mental status ∆s)
CLUES TO DIAGNOSIS
Smell for alcohol
Musty odor of Fetor Hepaticus
Fruity smell of DKA
Icterus &/or asterixis liver failure w/ serum ammonia
Agitation & tremulousness sedative or A/C withdrawal
Fever infx, heat illness, thyroid storm, ASA toxicity or
extreme adrenergic overflow of certain drug overdoses &
withdrawal syndromes (Esp. delirium tremens)
Extreme hyperthermia (w/pinpoint pupils) pontine strokes
BP = common in delirium b/c of resulting adrenergic
Hemotympanum, battle sign, raccoon eyes or otorhinorrhea
basilar skull fracture (2° to occult head trauma)
A rapid RR DKA (Kussmaul respiration), sepsis, stimulant
drug intoxication & ASA OD
A slow RR narcotic OD, CNS insult or various sedative
A rapid PR fever, sepsis, dehydration, thyroid storm & cardiac
dysrhythmias & stimulants, anticholinergics, quinidine,
theophylline, TCAs or ASA OD
A slow PR ICP, asphyxia, complete heart block, CCBs,
Digoxin & beta-blockers
Pupillary dilation intoxication w/ hallucinogen, amphetamine,
cocaine or anticholinergic med
Pupillary constriction narcotic intoxication
Pupillary inequality late sign of uncal herniation
A funduscopic examination:
– Loss of venous pulsations early ICP elevation
– Papilledema severe ICP
DIAGNOSIS -- Special cases:
In pts w/delirium & severely BP, check ocular fundi for
arteriolar spasm, disc pallor, papilledema, flame
hemorrhages & exudates ( Malignant HTN).
In pregnant pts w/diastolic pressure >75 mm hg in 2nd
trimester or >85 mm hg in 3rd trimester Pre-eclampsia
(Hyperreflexia, Edema, Proteinuria).
In pts w/HTN & Bradycardia ICP
With Delirium & Hypotension dehydration, diabetic
coma, hemorrhage due to trauma, aneurysmal rupture, GI
bleeding, adrenergic depletion (2° to cocaine, amphetamine
or TCA OD) & Addisonian crisis (particularly in steroid
A brief bedside neurologic exam, to include mental
status testing, is essential for workup of delirium
when a rapidly treatable cause (hypoglycemia or
narcotic OD) is not immediately apparent
The mini-mental status examination (MMSE) (a
formalized way of documenting severity & nature of
mental status ∆s)
In addition, or as an alternative to the MMSE,
correctly drawing the face of a clock (to include the
circle, numbers & hands) is a sensitive test of
Other simple screening tests include "serial 7's,"
CBC, electrolytes, BG levels, BUN/Cr
Also helpful – UA, LFTS (serum ammonia & PT), toxicology
screen, ABG, CXR, O2 Sat & cultures
Consider: Vitamin B-12 & Folate levels, VDRL test (r/o
Neurosyphilis) & thyroid function studies
Head CT scan [done b/f LP to r/o CNS infx, trauma, CVA, SAH,
hematomas, toxoplasmosis or abscess (especially in pts w/HIV
who present w/H/A)]
LP (CSF studies including India ink prep & VDRL)
Plain abdominal x-ray swallowed bags of drugs ("body
packing") or radiodense substances (iron tablets)
EKG (MI or a. fib; low voltages Hypothyroidism &
pericardial effusion; Tachycardia, widened QRS or prolonged QT
interval TCA overdose)
ABC’s + Normalize fluid & electrolyte status
Provide Thiamine when administering glucose [or else may lead to acute
Wernicke syndrome (ataxia, confusion, oculomotor palsies in the setting of
Physical or pharmacologic restraints (may be necessary to prevent pts from
harming self or others)
Low dose Haloperidol (Typical Antipsychotic doc for severe agitation,
acute psychosis & severe delirium when no CIs exist) [sedative qualities +
effect on DA-Ach balance; Assess for akathisia & EPS; Avoid in elderly
w/parkinsonism; in ICU, monitor for QT prolongation, torsades,
neuroleptic malignant syndrome & withdrawal dyskinesias; antidote:
Avoid sedative meds if possible [use Benzodiazepines Lorazepam (Ativan)
-- doc in ED (if unable to control a dangerous patient; may obscure the
Treat underlying cause
Multi-factorial approach is most successful
Highly distressing for pts & anxiety provoking for medical ward
Hospitalization is essential.
To limit confusion, foster trust & provide reassurance, try to ensure
that pt is nursed by same staff consistently.
Maximize visual acuity (e.g. Glasses, appropriately lit
environment) & hearing ability (e.g. Hearing aid, quiet
environment) to avoid misinterpretation of stimuli.
Involve friend or family member to remain w/pt to help comfort &
Avoid complications of delirium – remove indwelling devices
ASAP, prevent or treat constipation, urinary retention & encourage
proper sleep hygiene.
COURSE & PROGNOSIS
Average duration of delirium is 7 days
Inpatients who develop delirium have an ed
mortality, with elderly pts having up to a 75%
chance of dying during that admission
Delirium is fully reversible in most cases with
proper recognition & treatment of the etiology
Failure to dx & manage delirium is costly, life-
threatening & can lead to loss of function
WHAT IS DEMENTIA?
An acquired syndrome of decline in
memory and other cognitive functions
sufficient to affect daily life in an alert
Progressive and disabling
NOT an inherent aspect of aging
Different from normal cognitive lapses
DSM IV criteria:
Development of cognitive deficits manifested by both
-aphasia, apraxia, agnosia and disturbed executive
Significantly impaired social and occupational
Gradual onset and continuing decline
Not due to CNS and other physical or psychiatric
10% percent of persons over age 70
20 to 40% of individuals over age 85
Affects more than 4 million Americans
Costs more than $50 billion annually
Causes of Dementia & the
Vascular (multi-infarct) dementia
Dementia associated with Lewy bodies
ETOH, exposure to heavy metals (arsenic, antimony, bismuth)
Parkinson’s disease, Pick’s disease, frontal lobe dementia
Infectious diseases: These infections may be caused by viruses
(HIV, viral encephalitis); spirochetes (Lyme disease,
neurosyphilis); or prions (Creutzfeldt-Jacob disease)
Abnormal brain structure: Hydrocephalus, subdural hematoma
Most common REVERSIBLE
Dementia of depression
Onset and Duration of the memory loss
A) Elderly person with slowly progressive memory loss
over several years AD
B) Change in personality with disinhibition and
intact memory may suggest FTD
C) History of sudden stroke with an irregular
stepwise progression suggests Multi-infarct
D) Rapid progression with rigidity and
myoclonus suggests CJD
E) Gait disturbances+memory problems+resting
tremors may suggest PD
F) Multiple sex partners or intravenous drug use
may indicate CNS infection
G) Hx of Recurrent head trauma suggests
H) Alcoholism Thiamine deficiency
I) Gait disturbances,urinary incontinence and
memory problems suggest NPH
• Cogwheel rigidity, bradykinesiaPD
• Inability to initiate and coordinate stepsNPH
• Myoclonic jerks are present in CJD
• Hemiparesis or other focal neurologic deficits
• Dry cool skin,hair loss,bradycardia
– most widely used screening exam
– used in assessment and follow up
– score interpretation depends on patients age
and education level
– test of visuospatial skills
– draw numbers within a pre-drawn circle 3
inches in diameter to make that circle look like
the face of a clock
– Normal score 0-3
– Dementia 4-7
Name: hospital/floor/town/state/country 5 (1 for each name)
Identify three objects by name and ask patient to repeat3 (1 for each object)
Attention and calculation
Serial 7s; subtract from 100 (e.g., 93-86-79-72-65) 5 (1 for each subtraction)
Recall the three objects presented earlier 3 (1 for each object)
Name pencil and watch 2 (1 for each object)
Repeat "No ifs, ands, or buts“ 1
Follow a 3-step command (e.g., "Take this paper,,
fold it in half and place it on the table") 3 (1 for each command)
Write "close your eyes" and ask patient to obey 1
Ask patient to write a sentence 1
Ask patient to copy a design (e.g., intersecting pentagons) 1
Diffuse Lewy body
Slowly progressive dementing illness associated
with diffuse cortical atrophy, amyloid plaques and
• Progressive memory impairment (predominantly short term)
• Language impairment
• Complex deficits in visual and spatial abilities
• Personality changes - progressive passivity to marked
• Increased stubbornness & suspiciousness
• Symptoms of depression and anxiety
Brain slice: left from
right from normal brain CT SCAN
A. MRI BRAIN NORMAL 86-year-old
B. MRI BRAIN 77-year-old male with
c. Fluorodeoxyglucose PET scans of a
D. A patient with Alzheimer's disease.
Note that the patient
has decreased activity in the parietal
lobes bilaterally (arrows)
– KISS (keep it simple and short)
– Maintain autonomy and independence
– Establish routines
– Safety issues: cooking, driving, community
services referral, discuss legal issues, caregiver
– Medications: donepezil, tacrine
Reversible cholinesterase (ChE) inhibitor
In Alzheimer's disease behavioral consequences (e.g., decline in
memory and learning) that are partially related to cholinergic
Used for the symptomatic management of mild to moderate forms of
5 to 10mg qd
Liver disease, alcoholism, peptic ulcer disease, chronic
obstructive pulmonary disease; and bradycardia
N/V Diarrhea, Bradycardia Dizziness
Non-competitive antagonist at N-methyl-
D- aspartate receptors (NMDA)
Indicated for moderate to severe
Dose: 5 or 10 mg PO QD
Seizure disorder and renal disease are
HTN and Urinary Incontinence are the
Results from an accumulation of discrete
cerebral strokes that produce disabling deficits
of memory, behavior, and other cognitive
Focal neurologic deficits
Brain imaging shows multiple areas of stroke
Lewy Body Dementia
-Lewy bodies are intraneuronal inclusions that
stain with periodic acid-Schiff stain.
-In addition to chronic progressive dementia,
these patients often also have parkinsonian
-Frequent fluctuations of behavior, cognitive
ability,and level of alertness may occur.
-No specific treatment
-No response to L- DOPA
Lewy Body (cont.)
Presents as disinhibition, apathy, or agitation.
Focal lobar atrophy of the frontal and/or temporal
lobes seen on MRI.
Subcategory of FTD.
Microscopic findings include gliosis, neuronal loss,
and swollen or ballooned neurons, with Pick bodies.
Slowly progressive dementia ,bulimia, language
disturbance, emotional disinhibition, irritability,
and persistent aimless wandering,language
-Autosomal dominant degenerative brain disorder.
-Chorea and behavioral disturbance.
-Attention, judgment, awareness, may be seriously
deficient at an early stage.
-No specific treatment.
-Adventitious movements and behavioral changes
may partially respond to phenothiazines.
Atypical infectious agents called “prions” cause
It’s a transmissible neurodegenerative disorder.
Manifests in the sixth and seventh decade of life
as rapidly progressive dementia with myoclonus.
Minimal help with neuroimaging, EEG and CSF
CSF protein 14-3-3, may be diagnostic
but the gold standard is………?
Brain biopsy for premortem diagnosis.
Universal precautions are recommended for
routine patient care as the “prions” are very
resistant for routine disinfection methods.
The only known disease that can transmit through
corneal transplant and growth hormone
The disease in animals is called “bovine
No effective treatment.
Dementia in HIV occurs when the pt develops
AIDS(AIDS dementia complex).
-This is a diagnosis of exclusion based on
neuroimaging and spinal fluid analysis.
-Neuropsychiatric testing is helpful in
distinguishing from depression.
Pts have difficulty with cognitive tasks and have
diminished motor speed. Dementia manifestations
may wax and wane with periods of lucidity and
confusion over the course of a day.
First clinical symptom may be deterioration in
Many pts will improve with effective antiretroviral
Other types of dementia
Chronic metal intoxications
Caused by prolonged untreated thiamine deficiency
• Memory for new events is seriously impaired,
whereas memory of knowledge prior to the illness
is relatively intact
-MRI Mammillary body atrophy
-No specific treatment
-Thiamine (vitamin B1)deficiency damages the
thalamus, mammillary bodies.
-Administration of parenteral thiamine may
reverse the disease.
Develops due to loss of dopaminergic neurons in
Approximately 20% of patients develop dementia.
• Resting tremors
• Gait disturbances
Treatment with L-dopa neither accelerates nor
prevents this process.
Chronic metal intoxications
Dialysis dementia syndrome
Dementia is part of normal
processing of age…
Dementia impairs physical
functioning of the individual…
Delirious patient may have
A person with dementia may
A person with delirium will
A 70 YO man comes and tells you that
he has been forgetting certain things
and has difficulty of recollecting some
He is having dementia….?
True ? False ?