Delirium is an acute, potentially reversible brain dysfunction manifested by neuropsychiatric symptoms. It is common in hospitalized elderly patients, post-operatively, and in those withdrawing from alcohol. Core features include impaired consciousness, attention, cognition, and perception. Treatment involves identifying and addressing underlying causes, providing supportive care and reorientation, and administering antipsychotic medications like haloperidol to treat the delirium itself. Prognosis depends on severity and underlying causes, with higher mortality risks for those with longer or persistent delirium.

1. Delirium
Definition
● Delirium is an acute, potentially reversible
brain dysfunction manifested by a
syndromal array of neuropsychiatric
symptoms

2. Incidence
● Commonest of all Organic Brain Syndrome
● Most frequent syndrome seen by a psychiatrist on
CL
● App 20% of Pts seen
Clinical Features
● Core
● Associated
● Atypical features

3. Core features
● Consciousness - ↓ awareness, clouding
● Attention – Direct, Focus, Sustain, Shift
● Cognition – Memory, Language, Thought,
Orientation
● Perception – Fleeting illusions, hallucination and
delusions

4. Core features
● Rapid onset – hours to days
● fluctuating course – sundonning, lucid interval
● Brief – lasts for weeks ( < 6 months)
● Evidence of disease /toxic agent /cerebral
dysfunction

5. Associated features
Disturbances of
● Sleep wake of cycle – Insomnia and daytime
somnolence night mare
● Affect – anxiety, difficulty in marshaling own
thoughts ,emotional lability, irritability
● Psychomotor activity – Hypersensitivity to light and
sound
● Autonomic instability

6. Subtypes of delirium
● Hyperactive – Restlessness, hyper vigilance, rapid
speech, irritability and combativeness.
● Hypoactive – 9 to 31%, Withdrawn, slowed
speech, akinetic, apathy

7. Diagnostic criteria
ICD 10
● CS. + Attn.
● Global Distb. of
Cognition.
● PMA.
● SW Cycle.
● Emotional Distb.
● Rapid, Fluctuating Brief!
● Evidence of Cerebral
Dysfunction
DSM IV
● CS + Attn.
● Cognition (Memory
orientation language)
+ Perception.
● Rapid Fluctuations
● Cerebral Dys.

9. Special setting
Elderly
● Very common- 33-50%
● Onset subtle, gradual
● Hypoactive
● Features less marked
● Poorer prognosis, lasting impairments
● Comorbid – Dementia, Depression

10. Post – op
● Common- 10-20% ( upto 40% cardiac post
operative pts, 33% Hip surgery)
● Can be very severe -life threatening
● Emergence within 24 hrs
● Post op factors predispose

11. Delirium Tremens
● Florid –Rare – 5%
● Heavily dependent
● 2nd – 3rd day
● Hallucination, Delusion, Altered sensorium, Mood
changes, Tremors, Arousal
● 4 day – 1week – Recovery
● EEG – Fast activity
● High mortality

12. Pathophysiology
● Delirium itself is a disease
● Comorbid systemic disease may precipitate delirium,
but they do not cause it
● An analogy may help to clarify this proposed model.
“The flammability of the wood is the baseline vulnerability,
the matches are the precipitants, the fire is the etiopathogenic
engine and finally the light and heat are the cognitive and
behavioural manifestation of the delirium.”

13. Pathophysiology
● Neuronal integrity – Functional integrity of the neuron is of
paramount, importance. Disturbances are oxygen and
glutamate metabolism could be key factors involved.
● Role of oxygen: If PaO2 falls below 35-45 mm/Hg (Gibson et
al) frank delirium occurs.
● Anoxia – Selective vulnerability concepts given by Brown
applicable to delirium as well. He posited that hippocampus
fails first, followed by the neocortex, the subcortical nuclei,
the brainstem, cortical gray matter and finally the cerebellum.
● Neuroanatomical loci: No single neuroanatomical locus has
been pinpointed, but prefrontal and right-sided brain
dysfunction is seen.

14. Aetiology
● Infective
● Metabolic
● Vascular
● Neoplastic
● Endocrine
● Toxic
● Nutritional
● Degenerative
● Traumatic
● Anoxic
● Epileptic

15. Diagnostic and Liaison challenges
● Delirium is so common in ICU that some providers
have accepted it as an inevitable and even a natural
event in hospitalized elderly patients (Inouye 1994)
● Because delirium still is often viewed as a
syndrome caused by the patient’s systemic
illnesses, non-psychiatric physician feel reluctant
to consult a psychiatrist for help, so only
troublesome behavioural cases receive delirium –
specific treatment

16. Differential features of delirium,
dementia and psychosis
Characteristics Delirium Dementia Psychosis
Onset Sudden Insidious Sudden
Course over
24hr`s.
Fluctuating with
nocturnal
exacertrabtions
Stable Stable
Consciousness
Attention
Reduced Globally
disordered
Clear Normal except
in severe cases
Clear May be
disordered
Cognition Globally disordered Globally impaired May be Selectively
impaired
Hallucinations Visual or visual and
auditory
Often absent Auditory
Delusions Fleeting, poorly
systematized
Often absent Sustained and
systematized

17. Differential features of delirium,
dementia and psychosis
Characteristics Delirium Dementia Psychosis
Orientation Usually impaired
at least for time
Often impaired May be impaired
Psychomotor
activity
Increased, reduced
or shifting
unpredictably
Often normal Retarded or
hyperactive
depending on type
of psychosis
Speech Often incoherent,
slow or rapid
Difficulty in finding
words,
perseveration
Normal, slow or
rapid
Involuntary
movements
Often asterixis or
coarse tremor
Often absent Usually
EEG Abnormal, fast or
slow
Often abnormal
slow
Normal

18. Clinical Evaluation
Standard
● Complete history
● Medication review
● Neurological examination
● Vital signs
● Bedside testing – Mini Mental state examination,
clock drawing, a test for vigilance, days of the week
backward

19. As clinically warranted-Investigation
● Electrolyte
● Blood urea nitrogen
● Creatinine
● Glucose, Calcium
● Pulse oximetry
/ABG
● Urinalysis
● Drug screens
● LFT Cultures
● CSF examination
● Chest X-ray
● Electrocardiogram
● Brain imaging
● Electroencephalogram

20. Medication Review
● Furosemide
● Nifedipine
● Digoxin
● Isosorbide dinitrate
● Dipyridamole
● Warfarin
● Ranitidine
● Pradnislone
● Cimetidine
● Theophyiline
● Captropril

21. Interview and observation
● Main focus is on global image of the patient’s
cognitive functioning
● Decreased attention capacity
● Psychotic symptoms: delusion, hallucination
● Short-term memory deficit
● Executive dysfunction – Perseveration, Sequencing,
planning, organizing, change in mood.
● MMSE is 33% sensitive
● Mean MMSE score for Delirious patient – 14.3
● Control – 29.6

22. Neurological Examination
● Neuroimaging should be considered for patients
with head injuries, Focal findings, Cancer, Stroke
risks, AIDs
● Atypical presentations –
(i) Young
(ii) Healthy
(iii) Lack of identifiable precipitants

23. Treatment and Prevention
Non pharmacological interventions
● Among traditional treatments, non pharmacological
techniques clearly have a role in the management of
delirium
Interventions include
● Reorientation
● Board with names of care-team members
● Day’s schedule
● Clear communication to reorient to surroundings

24. Reorientation

25. Reorientation
● Board with names of
care-team members
● Day’s schedule
● Clear communication to
reorient to surroundings

26. Therapeutic activities protocol
Cognitively stimulating activities
three times daily e.g.
discussion of current events,
structured reminiscence,
word games.

27. Therapeutic activities protocol
Sleep deprivation
Non pharmacological sleep
protocol- at bedtime, warm drink
(mild or herbal tea)
Relaxation tapes or music
Back massage

28. Sleep enhancement protocol
● Unit/ward noise – reduction strategies
● Quite hall-ways
● Schedule adjustments to allow sleep e.g. rescheduling of
medications and procedures.
Immobility
● Early mobilization protocol
● Ambulation or active range of motion exercises three times
daily.
● Minimal use of immobilizing equipment (e.g. bladder
catheters, physical restraints)
Dehydration
● Early recognition of dehydration and volume repletion, i.e.
encouragement of oral intake fluids.

29. Pharmacotherapy
● Although environmental manipulations and
supportive care are important, medications offer
further advantages.
● Unless the delirium clears very rapidly or is mild,
concurrent use of delirium specific treatments is
also recommended.
● Antipsychotic medications are not just for
behavioural management but rather are disease
specific treatments for delirium.

30. Haloperidol
● Most studied and most widely accepted treatments for delirium
● Haloperidol as a first line agent.
● Has minimal anticholinergic effects (low likelihood of EPS),
minimal sedation or orthostasis
● Flexibility in dosing and administration with oral, I.M. or I.V.
routes
● Recommended dose – 1-2 mg every 2-4 hr as needed.
● Once stabilized – transitioned to a twice-daily or bedtime dose
● Slowly tapered until delirium has resolved.
In severe delirium refractory to boluses
● Continuous haloperidol infusion of 3-25 mg/hr have been used
safely with ECG monitoring (Risk of torse de pointis)

31. Atypical antipsychotics
● Risperidone, quetiapine, olanzapine have been
used to treat delirium successfully
● Parenteral olanzapine, when available, may
provide further benefits in treatments of delirium
● fast onset
● reduced EPS
● minimal concerns about QTc interval changes
Propofol- It decreases CBF and is associated with
hypotension; its use requires intubation and
artificial ventilation.

32. Prognosis
● Delirium as a “grave prognostic sign” (Lipowski ,1983)
● Death rate – 5.6-65%
● Metaanalysis (Cole 1993)-One month mortality 14.2%
;6 month mortality – 22.2%
● Duration- Average delirium episode is of 3-13 days,
mean – 20 days.
● Persistence beyond 7-40% (Gustafson 1988)
14-20% (O’ Keeffe 1997)
20-25% (Manor. 1997)
30 days – 13% (Sirol 1988)