Doctors Revision

Neurological System

Delirium

An acute clinical syndrome characterized by disturbances in attention, awareness, and cognition, with a fluctuating course. It represents acute brain dysfunction due to an underlying medical condition, substance intoxication/withdrawal, or medication effect.

Also known as: Acute Confusional State, Acute Organic Brain Syndrome, Toxic Metabolic Encephalopathy

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Referral and warning signs

When to refer

Delirium indicates serious underlying pathology. ALL patients with suspected delirium require prompt evaluation and management, usually necessitating hospital admission (H) to identify and treat the cause(s). Refer urgently if cause is unclear or requires specialist intervention (e.g., severe infection, stroke, metabolic emergency, complex withdrawal).

Red flags

  • Acute change in mental status
  • Fluctuating level of consciousness
  • Inattention
  • Signs of severe underlying illness (fever, hypoxia, hypotension, neurological deficits)
  • Potential life-threatening cause suspected (meningitis, stroke, severe metabolic disturbance, drug withdrawal)

Signs and symptoms

  • Acute Onset: Develops over hours to days.
  • Fluctuating Course: Symptoms tend to wax and wane, often worse at night ('sundowning').
  • Inattention: Reduced ability to direct, focus, sustain, and shift attention. Easily distractible.
  • Disordered Thinking: Disorganized thought processes, incoherent speech, tangentiality.
  • Altered Level of Consciousness: Ranges from hyperalert/agitated (hyperactive delirium) to lethargic/drowsy (hypoactive delirium), or mixed.
  • Cognitive Deficits: Impaired memory (especially recent), disorientation (time, place, person), language disturbance.
  • Perceptual Disturbances: Illusions (misinterpretations of real stimuli), Hallucinations (often visual, but can be auditory/tactile).
  • Psychomotor Disturbances: Restlessness, agitation, picking at bedclothes (hyperactive); or lethargy, reduced movement (hypoactive).
  • Sleep-Wake Cycle Disturbance: Insomnia, daytime drowsiness, reversal of cycle.
  • Emotional Disturbances: Anxiety, fear, irritability, anger, apathy, euphoria.

Risk factors

  • Underlying Medical Conditions:
  • - Infections: UTI, pneumonia, sepsis, malaria, meningitis, encephalitis, typhoid, HIV/AIDS.
  • - Metabolic/Endocrine: Electrolyte imbalances (Na+, Ca++, Mg++), hypo/hyperglycemia, hypoxia, hypercapnia, dehydration, severe anemia, thyroid disorders, liver failure (hepatic encephalopathy), renal failure (uremic encephalopathy).
  • - Neurological: Stroke, head trauma, brain tumor, seizures (post-ictal state), hypertensive encephalopathy.
  • - Cardiovascular: Heart failure, myocardial infarction, shock.
  • - Others: Severe pain, constipation, urinary retention, post-operative state.
  • Substance-Related:
  • - Intoxication: Alcohol, illicit drugs (cocaine, amphetamines), certain medications.
  • - Withdrawal: Alcohol withdrawal (esp. DTs), benzodiazepine withdrawal, sedative-hypnotic withdrawal.
  • Medications (Especially in elderly or polypharmacy): Anticholinergics (e.g., amitriptyline, chlorpheniramine, benzhexol), Benzodiazepines, Opioids, Sedative-hypnotics, Corticosteroids, Anticonvulsants, Antiparkinsonian drugs, certain antibiotics.
  • Pre-existing vulnerability: Advanced age, Dementia or baseline cognitive impairment, Severe illness, Sensory impairment (vision, hearing), Malnutrition, Immobility.

Diagnosis

Clinical assessment

Diagnosis is clinical, based on recognizing the characteristic features (acute onset, fluctuating course, inattention, altered consciousness/cognition) using criteria like CAM (Confusion Assessment Method). Requires a high index of suspicion, especially in elderly or acutely ill patients with changes in mental status. CRITICAL goal is to identify and treat the underlying cause(s). Obtain collateral history from family/carers about baseline function and acute changes.

Investigations

  • Guided by history and physical examination to find the underlying cause(s).
  • Basic Labs: Point-of-care Blood Glucose, CBC, Electrolytes, Renal function (Urea, Cr), Liver function (LFTs), Urinalysis (for UTI).
  • Infection screen: Malaria test (RDT/smear), Chest X-ray (pneumonia), Blood cultures, Lumbar puncture (if meningitis/encephalitis suspected - fever, neck stiffness, headache). Consider HIV test.
  • Consider: Thyroid function tests (TSH), Arterial Blood Gas (ABG - for hypoxia, hypercapnia, acidosis), Ammonia level (if liver failure), Toxicology screen (if intoxication/withdrawal suspected), ECG (arrhythmia, MI), CT Head (if trauma, focal signs, uncertain diagnosis).
  • Medication review: Carefully assess all prescribed and over-the-counter drugs for potential culprits.

Diagnostic criteria

Confusion Assessment Method (CAM) is a common bedside tool: Requires presence of 1 AND 2, PLUS either 3 OR 4. 1. Acute onset and fluctuating course. 2. Inattention. 3. Disorganized thinking. 4. Altered level of consciousness.

Management

Non-pharmacological management

  • Identify and Treat the Underlying Cause(s): This is the most important step. (e.g., treat infection, correct electrolytes/glucose, manage hypoxia, stop offending drug, treat pain, manage withdrawal).
  • Supportive Care: Ensure adequate hydration and nutrition. Optimize oxygenation. Manage fever.
  • Environmental Modifications: Provide calm, quiet environment. Ensure adequate lighting (esp. day vs night cues). Frequent reorientation (clocks, calendars, familiar objects/people). Encourage mobility if safe. Minimize room/staff changes.
  • Sensory Aids: Ensure patient has glasses/hearing aids if needed.
  • Family Involvement: Encourage family presence and participation in care/reassurance.
  • Avoid physical restraints if possible (can worsen agitation).

Pharmacological treatment

  • Medication Management: Review and discontinue non-essential/potentially deliriogenic medications.
  • Pharmacological Management of Agitation/Psychosis: Use ONLY if severe agitation, psychosis, or distress poses risk to patient or staff, AND non-pharmacological measures fail. Aim for lowest effective dose for shortest duration.
  • - Antipsychotics (Preferred agents): Haloperidol low dose (e.g., 0.5-2mg PO/IM, repeat q30-60min PRN if severe agitation, then scheduled 1.25-5mg q8-12h). Use lower doses in elderly. Monitor for QTc prolongation and extrapyramidal side effects (EPS). Atypical antipsychotics (e.g., Risperidone 0.25-1mg PO) may have lower EPS risk but other side effects.
  • - Benzodiazepines: Generally AVOIDED as they can worsen delirium, cause sedation, and increase fall risk. Exception: Indicated as first-line treatment for delirium due to alcohol or benzodiazepine withdrawal.
  • Treat underlying cause specifically (e.g., Thiamine for Wernicke's/alcohol withdrawal, Naloxone for opioid toxicity).

Monitoring

Monitor vital signs, oxygen saturation, fluid balance, glucose. Monitor mental status frequently (level of consciousness, attention, orientation, agitation level - CAM or similar tool). Monitor for side effects of medications used for sedation (EPS, QTc, sedation level). Monitor progress in identifying/treating underlying cause.

Complications

  • Increased morbidity and mortality
  • Prolonged hospital stay
  • Functional decline, loss of independence
  • Increased risk of institutionalization
  • Cognitive impairment may persist after resolution
  • Falls and injuries
  • Pressure sores
  • Aspiration pneumonia
  • Increased caregiver burden

Prevention

  • Identify high-risk patients.
  • Optimize environment (lighting, noise reduction, mobilization).
  • Ensure adequate hydration, nutrition, oxygenation.
  • Manage pain effectively.
  • Promote normal sleep-wake cycle (avoid unnecessary night disturbances).
  • Minimize use of psychoactive/deliriogenic medications.
  • Early treatment of infections and metabolic disturbances.
  • Use sensory aids (glasses, hearing aids).
  • Encourage family involvement.

Patient education

  • Explain to family/carers that delirium is a sign of underlying physical illness, not primary psychiatric disease.
  • Reassure that it is often temporary if the cause is treated.
  • Educate on supportive measures (reorientation, calm environment).
  • Explain the need for investigations to find the cause.
  • Discuss potential side effects if medications for agitation are used.

Uganda-specific notes

Common causes in Uganda include malaria, HIV/AIDS complications, TB meningitis, sepsis (UTI, pneumonia), typhoid, trypanosomiasis, alcohol withdrawal, and consequences of severe dehydration/malnutrition. Always consider infections. Access to comprehensive investigations (imaging, specific labs) may be limited, increasing reliance on clinical assessment and empirical treatment of likely causes. Antipsychotics like Haloperidol and Chlorpromazine are more likely available than atypicals.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 9, Section 9.1.6

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