Delirium

Objectives
Discuss various causes of delirium
Review diagnostic tests in the work-up of
delirium

Case
75 y/o M with DMII, COPD, and obesity is
hospitalized for a hip fracture. Patient was doing
well post-operatively with adequate pain
management and rehabilitation. On POD #3, he
forgets where he is, becomes more lethargic, and
refuses to eat. Patients temperature is 38.5, HR
105, RR 12, 90% on 2L NC.
What are the possible causes of this change in
mental status?
Definition of Delirium
Altered consciousness and cognition with the following
characteristics:
Poor attention
Develops over hours to days and fluctuating course during
the day.
Disturbance is likely from medical condition, substance
intoxication, or medication side effect.
Unlikely due to preexisting, established, or evolving
dementia.

Delirium
10-20% of all hospitalized adults
30-40% of elderly hospitalized patients
60% to 80% of mechanically ventilated
ICU patients
50% to 70% of non-ventilated ICU
patients

Delirium in older patients, Francis et al., Journal of the American Geriatrics Society.
1992;40(8):829
Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study.
Inouye SK et al., J Gen Intern Med. 1998;13(4):234.
Pointers on Assessment
ABCs and vitals first! Check GCS.
Try to obtain collateral information from family or
hospital staff
Get an understanding of patients baseline
mental status
What were the circumstances around the time
of change in mental status?
What is the duration of change?
Has it happened before?
What does the family think is going on?
AEIOU-TIPS mnemonic
Examples Possible Diagnostic Tests
A Alcohol, Ammonia
alcohol intoxication/withdrawal
elevated ammonia (hepatic
encephalopathy)
alcohol level
serum osmolality (toxic
alcohols)
ammonia
E Electrolytes/
Endocrine
hypoglycemia
hypo/hypernatremia
hypercalcemia
hypo/hyperthyroidism
addisonian crisis
DKA/HHNS
glucose
serum osmolality (HHNK)
serum electrolytes (esp Na, Ca)
thyroid function tests
serum cortisol level
I Iatrogenic
steroid psychosis
anticholinergics in elderly,
opiates, benzos
levels of medications
(anticonvulsants, digoxin,
theophylline,etc)
drug screen (street drugs,
sedatives, narcotics)
O Oxygen, opiates,
obstruction
pneumonia,
PE
carbon monoxide
opiate narcosis
oxygen
ABG
CXR
U Uremia
BUN
AEIOU-TIPS mnemonic


Examples Possible Diagnostic Tests
T Trauma
concussion
TIA/CVA
Hematoma
Head CT/ cervical spine CT
X-ray of any areas with trauma or deformity
MRI/MRA if indicated
I Infection
CBC with differential
Urinalysis and culture (UCG if appropriate)
Blood cultures and gram stain
Chest X-ray
Lumbar puncture (with opening pressure) - CT first if you
suspect increased ICP
P Poisoning
Levels of medications (anticonvulsants, digoxin,
theophylline,etc)
Drug screen (street drugs, sedatives, narcotics)
Alcohol level
Serum osmolality (toxic alcohols)
S Seizures Check anticonvulsant level
EEG/ MRI if indicated
Case
Patient could have multiple causes of his
delirium. A few of the possibilities include:
Infection given patients temperature and HR
(common post-op infections such as UTI and PNA)
Opiate toxicity given RR and O2 sat
Electrolyte imbalance
Hypoglycemia is possible if pt is on insulin and has
decreased po intake




Summary
Try to obtain collateral information
Use mnemonic AEIOU-TIPS to help
determine etiology and useful
diagnostic tests