Delirium

What is delirium?

Delirium is a severe state of confusion that includes rapid changes in level of consciousness. The most common causes are physical illness and the side effects of medicines. Delirium may develop over a few hours or several days. Periods of confusion come and go.

How does it occur?

Experts think delirium is caused by a change in the way the brain is working. Something either decreases the supply or use of oxygen in the brain or changes the chemicals in the brain. People with dementia (a permanent state in which the mind no longer works normally) are prone to delirium. Although poor vision and hearing do not cause delirium, they increase the risk that delirium will occur. This is especially true when older adults are in surroundings that are strange to them.

Medicines are the most common cause of delirium. The older adult may be taking many drugs, high doses of drugs, or drugs that are harmful when taken together. Also, the aging body does not process drugs as well as it used to because of changes in the liver and kidneys. Therefore, drugs can stay too long in the body and cause toxicity (poisoning). Nearly any medicine can cause or contribute to delirium, especially drugs used to treat:

• pain
• mental problems and depression
• stomach ulcers
• heart problems.

Even cold medicines sometimes cause confusion.

Almost any medical illness can lead to delirium. Common causes include conditions that result in:

• a decrease in the brain's oxygen supply
• low blood pressure
• changes in body chemistry
• low or high blood sugar.

Infections in the lungs and bladder or kidneys are also common causes. Delirium is less often caused by an actual change in the brain, such as by a stroke or a tumor. Pain can also contribute to delirium. People sometimes become confused after surgery due to the combination of being in a place that is strange to them and medicines, anesthesia, and stress.

Alcohol use and withdrawal can cause delirium. Delirium tremens (DTs) is probably the best known form of this condition. DTs can happen to a long-time heavy drinker who suddenly stops drinking. He or she may have tremors, seizures, and hallucinations (seeing or hearing things that are not there).

Delirium can also result from mental factors such as:

• depression
• grief
• lack of sleep
• feeling alone
• having too much or too little stimulation.

These conditions are very common among people who are in the hospital, especially those in the critical care unit (CCU) or intensive care unit (ICU). There may be no windows and no day and night routines in the ICU to help keep patients oriented. For many frail older adults, just having surgery is a risk factor for delirium. Delirium is a serious problem for the older adult in the hospital. They have less chance of a good recovery and more of a chance that they will die. Delirium is also common following a move into a nursing facility.

What are the symptoms?

Symptoms of delirium may include:

• agitation alternating with times of increased drowsiness
• mood swings (depression and fear are common)
• memory problems
• difficulty concentrating
• difficulty following directions
• sleep problems, including not being able to sleep at night and being sleepy during the day
• hallucinations, sometimes with delusions (false beliefs)
• rambling speech
• disorientation (the person may not know the time, the date, or his or her location or identity).

How is it diagnosed?

To find the cause of delirium, your healthcare provider will:

• take a complete history
• review medical problems and medicines
• do a physical exam
• order blood and urine tests.

Your healthcare provider may also order X-rays or special scans.

How is it treated?

Delirium is an emergency. Keep calm and try to protect the person from harm. If you cannot reach your healthcare provider right away, get emergency medical care. The causes must be found and treated. Even with proper treatment, delirium may not go away quickly. People will sometimes have to stay in hospital and will need to be watched closely until the confusion has cleared.

The following may be part of treatment:

• Help with personal care and meals is almost always needed for a time.
• Agitation and unruly behavior are common with delirium. They are managed with supportive care and, when needed, with medicine.
• Make surroundings as calm and quiet as possible, without background noise from TVs, radios, or distant conversation.
• Family, friends, doctors, and nurses can help calm the person and help the person to get his or her bearings.
• Glasses and hearing aids can help keep people who have poor hearing and eyesight from feeling isolated.
• Physical restraints should be used with great caution. They may make the person more upset and can lead to falls and injuries. Very rarely, they may be needed to prevent the person from removing an IV or a tube. When possible, a family member can sit with the person so restraints aren't needed.