Psych · Consultation-liaison psychiatry
Delirium
Also known as Acute confusional state · Acute encephalopathy · ICU delirium · Postoperative delirium · Delirium superimposed on dementia · Organic brain syndrome
Exam-exhaustive fellowship topic on delirium for consultation-liaison psychiatry — DSM-5-TR/ICD-11, CAM/4AT/CAM-ICU algorithms, hyperactive/hypoactive/mixed motor subtypes, predisposing and precipitating causes, medical work-up, multicomponent non-drug care first, limited antipsychotic role with trial evidence (MIND-USA, AID-ICU, Agar), ICU delirium and ABCDEF/PADIS, capacity, and discrimination from dementia and depression. FRANZCP-primary, globally tagged.
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- New fluctuating confusion with inattention — medical emergency until causes treated; do not rebadge as primary psychosis
- Hypoactive delirium (quiet, lethargic) — frequently missed and associated with worse outcomes
- Treating non-withdrawal delirium with benzodiazepines — often worsens confusion
- Routine high-dose antipsychotics without non-drug measures or cause treatment — not disease-modifying and potentially harmful
- Alcohol or benzodiazepine withdrawal delirium — needs benzodiazepines and thiamine, not antipsychotic monotherapy
- Assuming decision-making capacity is intact for discharge, consent, or self-discharge while delirious
- Wernicke risk (poor nutrition, alcohol) — give parenteral thiamine before prolonged glucose loads
Meet the patient
It is 3am. An 82-year-old woman, day two after a fractured neck of femur, is halfway over the cot side because she has to "catch the bus". Two hours ago the night nurse wrote settled. She has an indwelling catheter she did not have at home, PRN oxycodone, and has not opened her bowels since admission.[5][23]
The resident on the phone wants "something to settle her". The examiner wants something else, and it is the whole topic in one sentence: why has this brain, tonight, lost the ability to hold attention?[1][7]
Answer that and the sedative question usually disappears. Miss it and you will sedate a hypoxic, septic, constipated woman into a fall and a pneumonia.[5][6]
References24ShowHide
- [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]Ely EW, Inouye SK, Bernard GR, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) Crit Care Med, 2001.PMID 11445689
- [3]Ely EW, Margolin R, Francis J, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU) JAMA, 2001.PMID 11730446
- [4]Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients N Engl J Med, 1999.PMID 10053175
- [5]Marcantonio ER Delirium in Hospitalized Older Adults N Engl J Med, 2017.PMID 29020579
- [6]Oh ES, Fong TG, Hshieh TT, et al. Delirium in Older Persons: Advances in Diagnosis and Treatment JAMA, 2017.PMID 28973626
- [7]Wilson JE, Mart MF, Cunningham C, et al. Delirium Nat Rev Dis Primers, 2020.PMID 33184265
- [8]Girard TD, Exline MC, Carson SS, et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness N Engl J Med, 2018.PMID 30346242
- [9]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
- [10]Agar MR, Lawlor PG, Quinn S, et al. Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized Clinical Trial JAMA Intern Med, 2017.PMID 27918778
- [11]Burry L, Mehta S, Perreault MM, et al. Antipsychotics for treatment of delirium in hospitalised non-ICU patients Cochrane Database Syst Rev, 2018.PMID 29920656
- [12]Neufeld KJ, Yue J, Robinson TN, et al. Antipsychotic Medication for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta-Analysis J Am Geriatr Soc, 2016.PMID 27004732
- [13]Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU Crit Care Med, 2018.PMID 30113379
- [14]Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness N Engl J Med, 2013.PMID 24088092
- [15]Witlox J, Eurelings LS, de Jonghe JF, et al. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis JAMA, 2010.PMID 20664045
- [16]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
- [17]Marcantonio ER, Ngo LH, O'Connor M, et al. 3D-CAM: derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium: a cross-sectional diagnostic test study Ann Intern Med, 2014.PMID 25329203
- [18]Trzepacz PT, Mittal D, Torres R, et al. Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium J Neuropsychiatry Clin Neurosci, 2001.PMID 11449030
- [19]Bergeron N, Dubois MJ, Dumont M, et al. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool Intensive Care Med, 2001.PMID 11430542
- [20]Meagher DJ, Leonard M, Donnelly S, et al. A longitudinal study of motor subtypes in delirium: frequency and stability during episodes J Psychosom Res, 2012.PMID 22325705
- [21]Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis JAMA Intern Med, 2015.PMID 25643002
- [22]Hshieh TT, Yang T, Gartaganis SL, et al. Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness Am J Geriatr Psychiatry, 2018.PMID 30076080
- [23]Inouye SK, Charpentier PA Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability JAMA, 1996.PMID 8596223
- [24]American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults J Am Geriatr Soc, 2015.PMID 25495432