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CONFUSION AND DELIRIUM

PLM CM

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Hi guys! This trans is purely Harrisons-based (18 ed.)

OUTLINE
INTRODUCTION
CLINICAL FEATURES OF DELIRIUM
RISK FACTORS
EPIDEMIOLOGY
PATHOGENESIS
APPROACH TO THE PATIENT: DELIRIUM
o HISTORY
o PHYSICAL EXAMINATION
o ETIOLOGY
o LABORATORY AND DIAGNOSTIC EVALUATION
TREATMENT: DELIRIUM
PREVENTION

Confusion

Delirium

INTRODUCTION
a mental and behavioral state of reduced
comprehension, coherence, and capacity to
reason
one of the most common problems encountered
in medicine
accounting for a large number of emergency
department visits, hospital admissions, and
inpatient consultations
an acute confusional state
remains a major cause of morbidity and mortality
rates
costing billions of dollars yearly in health care
costs in the United States alone
often goes unrecognized despite clear evidence
that it is usually the cognitive manifestation of
serious underlying medical or neurologic illness.

CLINICAL FEATURES OF DELIRIUM

Delirium is a clinical diagnosis that can be made only at the
bedside.
Terms used encephalopathy
to describe acute brain failure
delirium
acute confusional state
postoperative or intensive care unit (ICU)
psychosis
Manifestation many clinical manifestations
defined as a relatively acute decline in
cognition that fluctuates over hours or days.
Hallmark of a deficit of attention, although all cognitive
Delirium
domainsincluding
memory,
executive
function, visuospatial tasks, and language
are variably involved.
Associated
altered sleep-wake cycles
symptoms
perceptual
disturbances
such
as
hallucinations or delusions
affect changes
autonomic findings that include heart rate and
blood pressure instability
Clinical
Two broad clinical categories:
categories
o Hyperactive Subtype
-Classic example: cognitive syndrome
associated with severe alcohol withdrawal
-prominent hallucinations, agitation, and
CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

Reversibilty
of delirium

Persistence
and
High
recurrence
rates

Effective
primary
prevention
strategy for
delirium

Two
Most
consistently
identified
risks

hyperarousal, often accompanied by lifethreatening autonomic instability

-easily recognized
Hypoactive Subtype
-Exemplified by: opiate intoxication
-withdrawn and quiet, with prominent
apathy and psychomotor slowing
-overlooked more often
-associated with worse outcomes
Based on differential psychomotor features
A useful construct, but patients often fall
somewhere along a spectrum between the
hyperactive and hypoactive extremes,
sometimes fluctuating from one to the other
within minutes.
Therefore, clinicians must recognize the
broad range of presentations of delirium to
identify all patients with this potentially
reversible cognitive disturbance.
Emphasized because many etiologies, such
as systemic infection and medication
effects, can be treated easily.
long-term cognitive effects of delirium
remain largely unknown and understudied
Some episodes of delirium continue for
weeks, months, or even years
In some instances, delirium does not
disappear because there is underlying
permanent neuronal damage.
Even after an episode of delirium resolves,
there may be lingering effects of the
disorder.
A patients recall of events after delirium
varies widely, ranging from complete amnesia
to repeated reexperiencing of the frightening
period of confusion in a disturbing manner,
similar to what is seen in patients with
posttraumatic stress disorder.
may be due to inadequate treatment of the
underlying etiology of the syndrome

RISK FACTORS
begins with identification of patients at
highest risk, including those preparing for
elective surgery or being admitted to the
hospital
no single validated scoring system has been
widely
accepted
as
a
screen
for
asymptomatic patients
multiple well-established risk factors for
delirium
older
age
and
baseline
cognitive
dysfunction
Individuals who are over age 65 or exhibit low
scores on standardized tests of cognition
develop delirium upon hospitalization at a
rate approaching 50%.
Its uncertain if the two is truly independent
risk factors.
Other predisposing factors:
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o
o

In-hospital
risks
for
delirium

Development
of
postoperative
delirium

Relationship
between
delirium and
dementia

Dementia
with
Lewy
bodies

Delirium
elderly

in

Development
of delirium

Delirium

sensory deprivation ( preexisting

hearing and visual impairment)
indices for poor overall health
(baseline immobility, malnutrition, and
underlying medical or neurologic
illness)

use of bladder catheterization

physical restraints
sleep and sensory deprivation
addition of three or more new medications

Avoiding such risks remains a key

component of delirium prevention as well
as treatment.
Surgical and anesthetic risk factors:
o specific procedures such as those
involving cardiopulmonary bypass
o inadequate or excessive treatment of
pain in the immediate postoperative
period
complicated by significant overlap between
the two conditions
not always simple to distinguish between
them
serve as major risk factors for delirium:
o Dementia
o preexisting cognitive dysfunction
at least 2/3 of cases of delirium occur in
patients with coexisting underlying dementia
A form of dementia with parkinsonism
characterized by:
o fluctuating course
o prominent visual hallucinations
o parkinsonism
o attentional
deficit
that
clinically
resembles hyperactive delirium.
often reflects an insult to the brain that is
vulnerable
due
to
an
underlying
neurodegenerative condition
sometimes heralds the onset of a previously
unrecognized brain disorder.

EPIDEMIOLOGY
a common disease
reported incidence has varied widely with the
criteria used to define the disorder
Estimates of delirium in hospitalized patients
range from 14 to 56%, with higher rates reported
for elderly patients and patients undergoing hip
surgery.
Older patients in the ICU have especially high
rates of delirium that range from 70 to 87%.
not recognized in up to 1/3 of delirious inpatients
Delirium in the ICU:
o Diagnosis
is
problematic
(cognitive
dysfunction is often difficult to appreciate in
the setting of serious systemic illness and
sedation)
o should be viewed as an important
manifestation of organ dysfunction not
unlike liver, kidney, or heart failure.
Outside the acute hospital setting
o delirium occurs in nearly 2/3 of patients in
nursing homes and in over 80% of those at

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

In
previous
decades
Now

the end of life.

These estimates emphasize the remarkably
high frequency of this cognitive syndrome in
older patients, a population expected to grow
in the upcoming decade with the aging of the
baby boom generation.
an episode of delirium was viewed as a transient
condition that carried a benign prognosis.

Delirium now has been clearly associated with

substantial morbidity rate and increased
mortality rate and increasingly is recognized as a
sign of serious underlying illness.
Recent estimates of in-hospital mortality rates
among delirious patients have ranged from 25 to
33%, a rate similar to that of patients with sepsis.
Patients with an in-hospital episode of delirium
have a higher mortality rate in the months and
years after their illness compared with agematched nondelirious hospitalized patients.
Delirious hospitalized patients have a longer length
of stay, are more likely to be discharged to a
nursing home, and are more likely to experience
subsequent episodes of delirium; as a result, this
condition has enormous economic implications.

PATHOGENESIS
Pathogenesis
and incompletely understood
anatomy of delirium
Attentional deficit
serves as the neuropsychological
hallmark of delirium
appears to have a diffuse
localization with the brainstem,
thalamus, prefrontal cortex, and
parietal lobes.
Focal lesions
such as ischemic strokes
rarely, have led to delirium in
otherwise healthy persons
right parietal and medial dorsal
thalamic lesions have been
reported most commonly, pointing
to the relevance of these areas to
delirium pathogenesis
Cortical
and Widespred disturbances in these
subcortical regions
regions cause delirium
Cause of delirium in most cases
rather than a focal neuroanatomic
cause
Electroencephalogram usually show symmetric slowing, a
(EEG)
nonspecific finding that supports
diffuse cerebral dysfunction, in
persons with delirium
Acetylcholine
often plays a key role in delirium
deficiency
pathogenesis
Medications
with can
precipitate
delirium
in
anticholinergic
susceptible individuals,
Therapies
with designed to boost cholinergic tone
cholinergic properties
e.x. cholinesterase inhibitors
have, in small trials, been shown to
relieve symptoms of delirium
Dementia patients
susceptible to episodes of delirium
Those
with
Alzheimers
pathology
o known to have a chronic
cholinergic deficiency state
due to degeneration of
acetylcholine-producing
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Other
neurotransmitters

Not all individuals

exposed to the same
insult will develop
signs of delirium

Exposure to known
inciting factors

neurons
in
the
basal
forebrain
Dementia with Lewy bodies
o Another common dementia
associ- ated with decreased
acetylcholine levels
o clinically mimics delirium in
some patients
are also likely to be involved in this
diffuse cerebral disorder
For
example,
increases
in
dopamine can also lead to
delirium.
o Patients with Parkinsons
disease
treated
with
dopaminergic
medications
can develop a delirium-like
state that features visual
hallucinations, fluctuations,
and confusion.
reducing dopaminergic tone with
dopamine antagonists such as
typical and atypical antipsychotic
medications
has
long
been
recognized
as
effective
symptomatic
treatment
in
patients with delirium.

low dose of anticholinergic:

o
may have no cognitive
effects on a healthy young
adult
o may produce a florid delirium
in an elderly person with
known underlying dementia.
extremely high dose of the same
anticholinergic may lead to delirium
even in healthy young persons.
This
concept
of
delirium
developing as the result of an
insult in predisposed individuals
is currently the most widely
accepted pathogenic construct.
if a previously healthy individual
with no known history of cognitive
illness develops delirium in the
setting of a relatively minor insult
such as elective surgery or
hospitalization, an unrecognized
underlying neurologic illness such
as a neurodegenerative disease,
multiple previous strokes, or
another diffuse cerebral cause
should be considered.
delirium can be viewed as the
symptom resulting from a stress
test for the brain induced by the
insult.
such as systemic infection and
offending drugs
can unmask a decreased cerebral
reserve
can herald a serious underlying and
potentially treatable illness

APPROACH TO THE PATIENT: DELIRIUM

Diagnosis
clinical and is made at the bedside
CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

Screening
tools

Using CAM

Acutely
confused
patients
Not
essential
for
diagnosis
Observation
Other
hallmark
features

Accurate
history
Information
from
collateral
source
3
Most
important
pieces
of
history
Premorbid
cognitive
function
Delirium by
definition

careful history and physical examination is

necessary in evaluating patients with possible
confusional states
can aid physicians and nurses in identifying
patients with delirium
o Confusion Assessment Method (CAM)
o Organic Brain Syndrome Scal
o Delirium Rating Scale
o Delirium Detection Score (in ICU)
o ICU version of the CAM
These scales are based on criteria from the
American
Psychiatric
Associations
Diagnostic and Statistical Manual of Mental
Disorders (DSM) or the World Health
Organizations International Classification
of Diseases (ICD)
These scales do not identify the full spectrum
of patients with delirium.

diagnosis of delirium is made if there is

acute onset and fluctuating course

inattention accompanied by either

disorganized thinking or

altered level of consciousness.

should be presumed delirious regardless of
their presentation due to the wide variety of
possible clinical features.
A typical course that fluctuates over hours or
days and may worsen at night (termed
sundowning)
Will reveal an altered level of consciousness or
a deficit of attention.
alteration of sleep-wake cycles
thought disturbances such as hallucinations or
delusions
autonomic instability
changes in affect.
HISTORY
difficult to elicit in delirious patients who have
altered levels of consciousness or impaired
attention
such as a spouse or another family member is
invaluable.
patients baseline cognitive function
the time course of the present illness
current medications
can be assessed through the collateral source
or, if needed, via a review of outpatient records
represents a change that is relatively acute,
usually over hours to days, from a cognitive
baseline.
As a result, an acute confusional state is nearly
impossible to diagnose without some
knowledge of baseline cognitive function.
Without this information, many patients with
dementia or depression may be mistaken as
delirious during a single initial evaluation.
Patients with a more hypoactive, apathetic
presentation with psychomotor slowing may be
identified as being different from baseline only
through conversations with family members.
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Time
course
of
cognitive
change

Medications

Other
important
elements of
the history

General

Neurologic

A number of validated instruments have been

shown to diagnose cognitive dysfunction
accurately by using a collateral source:
o modified Blessed Dementia Rating
Scale
o Clinical Dementia Rating (CDR).
Baseline cognitive impairment is common in
patients with delirium.
Even when no such history of cognitive
impairment is elicited, there should still be a
high suspicion for a previously unrecognized
underlying neurologic disorder
Establishing this is important not only to make
a diagnosis of delirium but also to correlate
the onset of the illness with potentially
treatable
etiologies
such
as
recent
medication changes or symptoms of systemic
infection.
remain a common cause of delirium,
especially compounds with anticholinergic or
sedative properties
1/3 of all cases of delirium are secondary to
medications, especially in the elderly.
Medication histories should include
o all prescription as well as over-thecounter
o herbal substances taken by the patient
o any recent changes in dosing or
formulation
o substitution of generics for brand-name
medications.
screening for symptoms of organ failure or
systemic infection, which often contributes to
delirium in the elderly
common in younger delirious patients:
o A history of illicit drug use
o Alcoholism
o toxin exposure
other symptoms that may accompany delirium,
such as depression and hallucinations, may
help identify potential therapeutic targets.
PHYSICAL EXAMINATION
Careful screening for signs of
infection
o Fever
o Tachypnea
o pulmonary consolidation
o heart murmur
o stiff neck
fluid status should be assessed; both
dehydration and fluid overload with
resultant hypoxemia have been
associated with delirium, and each is
usually easily rectified
appearance of the skin can be
helpful
o jaundice
in
hepatic
encephalopathy
o cyanosis in hypoxemia
o needle tracks in patients using
intravenous drugs
requires a careful assessment of
mental status
Patients with delirium often present
with a fluctuating course
diagnosis can be missed when one
relies on a single time point of

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

Altered level
consciousness

of

Patients w/ normal
level
of
consciousness

evaluation
Some but not all patients exhibit the
characteristic pattern of sundowning,
a wors- ening of their condition in the
evening.
In these cases, assessment only
during morning rounds may be falsely
reassuring.
ranging from hyperarousal to lethargy
to coma is present in most patients
with delirium
can be assessed easily at the bedside

screen for an attentional deficit

(classic
neuropsychological
hallmark of delirium)

Attention

can be assessed while taking a history

from the patient
Tangential speech
o fragmentary flow of ideas, or
inability to follow complex
commands often signifies an
attentional problem
There are formal neuropsychological
tests to assess attention, but a simple
bedside test of digit span forward is
quick and fairly sensitive.
In this task, patients are asked to
repeat successively longer random
strings of digits beginning with two
digits in a row.
Average adults can repeat a string of
five to seven digits before faltering; a
digit span of four or less usually
indicates an attentional deficit unless
hearing or language barriers are
present.

Forman
neuropsychological
testing

can be extraordinarily helpful in

assessing a delirious patient
usually too cumbersome and timeconsuming in the inpatient setting
can
provide
some
information
regarding orientation, language, and
visuospatial skills
performance of some tasks on the
MMSE such as spelling world
backward and serial subtraction of
digits will be impaired by delirious
patients attentional deficits alone and
are therefore unreliable
Focus of remainder of the screening
neurologic examination
Focal strokes or mass lesions in
isolation
o rarely the cause of delirium, but
patients
with
underlying
extensive
cerebrovascular
disease or neurodegenerative
conditions may not be able to
cognitively
tolerate
even
relatively small new insults

Screen for parkinsonism, which is

seen not only in idiopathic Parkinsons
disease but also in other dementing
conditions
such
as
Alzheimers

Simple Mini Mental

Status Examination
(MMSE)

New
focal
neurologic deficits

Signs
of
neurodegenerative
conditions

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MEDICINE 1 // CONFUSION AND DELIRIUM

disease, dementia with Lewy bodies,

and progressive supranuclear palsy.
presence of multifocal myoclonus or
asterixis is nonspecific but usually
indicates a metabolic or toxic
etiology of the delirium.

Motor examination

Etiologies

Prescribed,
pver-thecounter,
and
herbal
medications

Illicit drugs and

toxins

Metabolic
abnormalities

ETIOLOGY
Some can be easily discerned through a
careful history and physical examination
others require confirmation with laboratory
studies, imaging, or other ancillary tests
A large, diverse group of insults can lead
to delirium, and the cause in many
patients is often multifactorial.
common precipitants of delirium
Drugs with anticholinergic properties,
narcotics, and benzodiazepines are
especially common offenders, but nearly
any compound can lead to cognitive
dysfunction in a predisposed patient.
elderly patient with baseline dementia
may become delirious upon exposure to a
relatively low dose of a medication
less susceptible individuals may become
delirious only with very high doses of the
same medication
importance of correlating the timing of
recent medication changes, including
dose and formulation, with the onset of
cognitive dysfunction
common causes of delirium, especially in
younger patients
increase in delirious young persons
presenting to acute care settings due to
recent rise in availability of so-called club
drugs,
o methylenedioxymethamphetamine
(MDMA, ecstasy),
o -hydroxybutyrate (GHB)
o phencyclidine (PCP)-like agent
ketamine
Many common prescription drugs such as
oral narcotics and benzodiazepines are
often abused and readily available on the
street.
Alcohol intoxication with high serum
levels can cause confusion
withdrawal from alcohol
o more commonly leads to a classic
hyperactive delirium
Alcohol and benzodiazepine withdrawal
o should be considered in all cases
of delirium
o patients who drink only a few
servings of alcohol every day can
experience
relatively
severe
withdrawal
symptoms
upon
hospitalization
electrolyte disturbances of sodium,
calcium, magnesium, or glucose
o can cause delirium
mild derangements
o can lead to substantial cognitive
disturbances
in
susceptible
individuals
Other common metabolic etiologies:

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

liver and renal failure

hypercarbia and hypoxemia
vitamin deficiencies of thiamine
and B12
o autoimmune disorders including
central nervous system (CNS)
vasculitis
o
endocrinopathies such as thyroid
and adrenal disorders.
often cause delirium, especially in the
elderly
common scenario
o involves the development of an
acute cognitive decline in the
setting of a urinary tract infection
in a patient with baseline
dementia.
Pneumonia, skin infections such as
cellulitis, and frank sepsis also can lead to
delirium.
septic encephalopathy
o often seen in the ICU
o probably due to the release of
proinflammatory cytokines and
their diffuse cerebral effects.
CNS infections
o such as meningitis, encephalitis,
and abscess
o less common etiologies of delirium
o high mortality rates associated with
these conditions when they are not
treated quickly,
o clinicians must always maintain a
high index of suspicion.
In some susceptible individuals, this can
lead to delirium.
usually occurs as part of a multifactorial
delirium
should be considered a diagnosis of
exclusion after all other causes have
been thoroughly investigated
Many primary prevention and treatment
strategies for delirium involve relatively
simple methods to address the aspects of
the inpatient setting that are most
confusing.
usually due to global hypoperfusion in the
setting of systemic hypotension from
heart failure, septic shock, dehydration, or
anemia.
Focal strokes in the right parietal lobe
and medial dorsal thalamus
o rarely can lead to a delirious state
new focal stroke or hemorrhage
o more common scenario causring
confusion in a patient who has
decreased cerebral reserve
o sometimes difficult to distinguish
between
cognitive
dysfunction
resulting
from
the
new
neurovascular insult itself and
delirium due to the infectious,
metabolic,
and
pharmacologic
complications that can accompany
hospitalization after stroke.
intermittent seizures
o may be overlooked when one is
considering potential etiologies,
o
o
o

Systemic
infections

Exposure
to
unfamiliar
environment of a
hospital

Cerebrovascular
etiologies

Seizures

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Terminal
restlessness

because a fluctuating course often

is seen in delirium
nonconvulsive status epilepticus and
recurrent focal or generalized seizures
followed by postictal confusion
o can cause delirium
o EEG remains essential for this
diagnosis.
Seizure activity spreading from an
electrical focus in a mass or infarct can
explain global cognitive dysfunction
caused by relatively small lesions.
patients experience delirium at the end of
life in palliative care settings
must
be
identified
and
treated
aggressively
an important cause of patient and family
discomfort at the end of life
It should be remembered that these
patients also may be suffering from more
common etiologies of delirium such as
systemic infection.

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

LABORATORY AND DIAGNOSTIC EVALUATION

Cost approach to the diagnostic evaluation of delirium
effective
that allows the history and physical examination
to guide tests
No established algorithm for workup will fit all
delirious patients due to the staggering number
of potential etiologies
o one stepwise approach is detailed in
Table 25-2.
If a clear precipitant is identiied early
o such as an offending medication
o little further workup is required
If no likely etiology is uncovered with initial
evaluation
o an aggressive search for an underlying
cause should be initiated
Basic
Should be obtained in all patients w/ delirium:
screening
o complete blood count
labs
o electrolyte panel
o tests of liver and renal function
In elderly patients
o screening for systemic infection is
important
o chest radiography
o urinalysis and culture
o possibly blood cultures
In younger individuals
o serum and urine drug and toxicology
screening may be appropriate early in the
workup.
patients in whom the diagnosis remains
unclear after initial testing
o Additional laboratory tests addressing
other
autoimmune,
endocrinologic,
metabolic, and infectious etiologies
should be reserved.
Brain
often unhelpful
imaging
if the initial workup is unrevealing
o most clinicians quickly move toward
imaging of the brain to exclude structural
causes.
noncontrast CT scan
o can
identify
large
masses
and
hemorrhages
o relatively insensitive for discovering an
etiology of delirium
MRI
Able to identify most acute ischemic strokes
provides neuroanatomic detail that gives clues to
possible
infectious,
inflammatory,
neurodegenerative, and neoplastic conditions
test of choice
MRI techniques are limited by:
o availability
o speed of imaging
o patient cooperation
o contraindications to magnetic exposure
Many clinicians begin with CT scanning and
proceed to MRI if the etiology of delirium
remains elusive
Lumbar
must be obtained immediately after appropriate
puncture
neuroimaging in all patients in whom CNS infec(LP)
tion is suspected.
Spinal fluid examination
o can also be useful in identifying
inflammatory and neoplastic conditions
and
o diagnosis of hepatic encephalopathy
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MEDICINE 1 // CONFUSION AND DELIRIUM

EEG

Management
of delirium

through elevated cerebrospinal fluid (CSF)

glutamine levels.
LP should be considered in any delirious patient
with a negative workup.
does not have a routine role in the workup of
delirium
remains invaluable if seizure-related etiologies
are considered

Simple
methods of
supportive
care

TREATMENT: DELIRIUM
begins with treatment of the underlying
inciting factor
o patients with systemic infections should
be given appropriate antibiotics
o underlying electrolyte disturbances
judiciously corrected
These treatments often lead to prompt
resolution of delirium.
Blindly targeting the symptoms of delirium
pharmacologically
o only serves to prolong the time patients
remain in the confused state
o may
mask
important
diagnostic
information
medications used to boost cholinergic
tone in delirious patients
o led to mixed results
o not currently recommended

Acute
management

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

can be highly effective in treating patients with

delirium
Can reduce confusion:
o Reorientation by the nursing staff and
family
o visible clocks and calendars
o outside-facing windows
Sensory isolation
o should be prevented by providing
glasses and hearing aids to patients
who need them
Sundowning
o can be addressed to a large extent
through vigilance to appropriate sleepwake cycles.
During the day
o a well-lit room should be accompanied
by activities or exercises to prevent
napping.
At night
o a quiet, dark environment
o limited interruptions by staff
o assure proper rest
sleep-wake cycle interventions
o important in the ICU setting as the
usual constant 24-h activity commonly
provokes delirium
Attempting to mimic the home environment
as much as possible
o has been shown to help treat and even
prevent delirium.
Visits from friends and family throughout
the day
o minimize the anxiety associated with
the constant flow of new faces of staff
and physicians.
Allowing hospitalized patients to have access
to home bedding, clothing, and nightstand
objects
o makes the hospital environment less
foreign and therefore less confusing.
Simple standard nursing practices:
o Ex. maintaining proper nutrition and
volume status
o Ex. managing incontinence and skin
breakdown
o help alleviate discomfort and resulting
confusion

required in some instances where patients

pose a threat to their own safety or to the
safety of staff members
Bed alarms and personal sitters vs physical
restraints
o more effective
o much less disorienting
Chemical restraints
o should be avoided
o when necessary, very low dose typical
or atypical antipsychotic medications
administered on an as-needed basis
are effective.
association of antipsychotic use in the
elderly with increased mortality rates
o underscores the importance of using
these medications judiciously and only
as a last resort
Benzodiazepines
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MEDICINE 1 // CONFUSION AND DELIRIUM

o
o
o
o

not as effective as antipsychotics

often worsen confusion through their
sedative properties.
Still used by many clinicians to treat
acute confusion
use should be limited to cases in which
delirium is caused by alcohol or
benzodiazepine withdrawal

PREVENTION
It is extremely important to develop effective strategy to
prevent delirium in hospitalizations, because of:
o high morbidity associated with delirium
o
tremendously increased health care costs that
accompany it
First step:
o Successful identification of high-risk patients
followed by:
o initiation of appropriate interventions
One trial randomized more than 850 elderly inpatients to
simple standardized protocols used to manage risk factors for
delirium, including cognitive impairment, immobility, visual
impairment, hearing impairment, sleep deprivation, and
dehydration.
Significant reductions in the number and duration of
episodes of delirium were observed in the treatment group,
but unfortunately, delirium recurrence rates were
unchanged.
Recent trials in the ICU have focused on identifying sedatives,
such as dexmedetomidine, that are less likely to lead to
delirium in critically ill patients.
All hospitals and health care systems should work toward
developing standardized protocols to address common risk
factors with the goal of decreasing the incidence of delirium.

CALDERON, GARCIA, HARDIN, MANABAT, SOLIS

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