Phys · geriatric
Delirium
Also known as acute confusional state · acute brain failure · acute cognitive decline · postoperative delirium · ICU delirium · hypoactive delirium · hyperactive delirium · terminal delirium · CAM · Confusion Assessment Method · HELP · Hospital Elder Life Program
Consultant-physician-depth guide to delirium for FRACP DWE and DCE — DSM-5 definition, the Confusion Assessment Method, hyperactive versus hypoactive subtypes, neuroinflammatory and cholinergic pathophysiology, the DELIRIUM mnemonic for precipitants, HELP prevention, multicomponent non-pharmacological management, the narrow role of haloperidol, and the differentiation from dementia and depression.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- Acute onset of confusion in any older adult is delirium until proven otherwise — never assume dementia without documenting acute change
- Hypoactive delirium is the most commonly missed subtype — the quiet, lethargic patient is being missed while the agitated patient is over-treated
- New agitation, hallucinations or fluctuating consciousness in a patient with Parkinson disease or dementia with Lewy bodies — never give haloperidol or typical antipsychotics (catastrophic neuroleptic sensitivity)
- Delirium with fever, neck stiffness or focal neurological signs — exclude meningitis, encephalitis, intracranial haemorrhage with urgent imaging and lumbar puncture
- Alcohol or benzodiazepine withdrawal delirium (delirium tremens) — benzodiazepines are the correct treatment, not contraindicated, and untreated withdrawal is life-threatening
- Persistent delirium beyond 1 to 2 weeks — search for ongoing precipitants (occult infection, drug, pain, constipation, urinary retention) and reassess
Delirium
The answer first
Delirium is acute brain failure — an acute, fluctuating disturbance of attention and awareness caused by a medical condition, a drug, or withdrawal. It is the commonest acute neuropsychiatric complication of hospitalisation in older adults, and you will miss it in roughly half of cases.[1]
Three rules run the whole topic. First, acute confusion is delirium until proven otherwise — never blame dementia without documenting an acute change from baseline, anchored to a collateral history. Second, delirium is multifactorial — the patient rarely has a single cause; infection plus dehydration plus an anticholinergic plus urinary retention is the ward classic, so find and treat every precipitant. Third, the management is cause-directed and non-pharmacological — haloperidol is the last resort, reserved for severe distress or danger.[1]
The classic trap: when the exam asks "best initial management of delirium," the answer is almost always identify and treat the cause with multicomponent non-pharmacological care — never haloperidol first. And haloperidol must never touch a patient with Parkinson disease or dementia with Lewy bodies.[1]
References8ShowHide
- [1]Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium Ann Intern Med, 1990.PMID 2240918
- [2]Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients N Engl J Med, 1999.PMID 10053175
- [3]Inouye SK Delirium in older persons N Engl J Med, 2006.PMID 16540616
- [4]Witlox J, Eurelings LSM, de Jonghe JFM, et al. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis JAMA, 2010.PMID 20664045
- [5]Inouye SK, Westendorp RGJ, Saczynski JS Delirium in elderly people Lancet, 2014.PMID 23992774
- [6]Bellelli G, Morandi A, Davis DH, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people Age Ageing, 2014.PMID 24590568
- [7]Page VJ, Ely EW, Gates S, et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial Lancet Respir Med, 2013.PMID 24461612
- [8]Andersen-Ranberg NC, Poulsen LM, Perner A, et al. Haloperidol for the Treatment of Delirium in ICU Patients N Engl J Med, 2022.PMID 36286254