Diferencia entre revisiones de «Delirium»

(Text replacement - "==Diagnosis==" to "==Evaluation==")
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==Background==
==Background==
*Also known as "acute toxic-metabolic encephalopathy"
*Acute disturbance of consciousness with fluctuating inattention and cognitive dysfunction
*Delirium vs. [[dementia]] vs. psych
*Caused by an underlying medical condition — NOT a primary psychiatric disorder
*Extremely common: affects 10-30% of hospitalized elderly patients
*Associated with increased mortality, prolonged hospitalization, and long-term cognitive decline
*Key distinction from [[dementia]]: Delirium is acute (hours-days), fluctuating, with inattention as primary deficit; dementia is chronic (months-years) with memory as primary deficit


==Clinical Features==
==Clinical Features==
*Main cognitive impairment is that of inattention (vs memory in dementia)  
*Inattention — hallmark feature (cannot maintain or shift attention appropriately)
*Generally develops over hours to days
*Fluctuating course throughout the day
*Symptoms are classically described as fluctuating throughout the day (ie may appear normal in between episodes)
*Develops over hours to days (acute onset)
*Subtypes:
**Hyperactive: agitation, restlessness, hallucinations, combativeness (easier to diagnose)
**Hypoactive: lethargy, decreased responsiveness, withdrawn (frequently missed — more common and more dangerous)
**'''Mixed:''' alternating between hyperactive and hypoactive states


===ED Confusion Assessment Method<ref>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; 113:941.</ref>===
===Common Causes (mnemonic: DELIRIUM)===
*Acute onset of mental status changes and/or fluctuating course
*Drugs (anticholinergics, opioids, benzodiazepines, steroids, polypharmacy)
*Anattention
*Electrolyte abnormalities, Endocrine (thyroid, adrenal, glucose)
*Disorganized thinking
*Lack of drugs (withdrawal from alcohol, benzodiazepines, opioids)
*Altered level of consciousness
*Infection (UTI, pneumonia, meningitis, sepsis)
*Reduced sensory input (vision/hearing impairment, ICU environment)
*Intracranial pathology (stroke, hemorrhage, mass, seizure)
*Urinary retention, constipation (especially in elderly)
*Myocardial/pulmonary (MI, PE, hypoxia, CHF)


A patient must possess both features 1 and 2 AND either 3 or 4 to meet delirium criteria
===Confusion Assessment Method (CAM)===
*Must have '''both''' features 1 AND 2 '''plus''' either 3 OR 4:
*#Acute onset and/or fluctuating course
*#Inattention
*#Disorganized thinking
*#Altered level of consciousness


==Differential Diagnosis==
==Differential Diagnosis==
{{AMS DDX}}
{{AMS DDX}}
{{Psych DDX}}
{{Psych DDX}}


==Evaluation==
==Evaluation==
''Main goal is to find the underlying cause''
*Goal: identify and treat the underlying cause
{{AMS workup}}
{{AMS workup}}
*Minimum: glucose, BMP, CBC, urinalysis, [[ECG]], [[CXR]]
*Consider: LFTs, ammonia, TSH, blood cultures, lactate, [[urine toxicology screen]]
*CT head if: focal neuro findings, fall/head trauma, anticoagulation, no clear cause identified
*LP if meningitis/encephalitis suspected


==Management==
==Management==
*Treat underlying cause
*Treat the underlying cause — this is the definitive management
*Antipsychotics (eg haloperidol, risperidone) may be useful for hyperactive delirium with psychotic features
*Non-pharmacologic measures first: reorientation, quiet environment, sleep-wake cycle preservation, mobilization, adequate hydration/nutrition, correct sensory deficits (glasses, hearing aids)
*Pharmacologic (for severe hyperactive delirium with safety concerns):
**[[Haloperidol]] 0.5-2 mg IV/IM (start low in elderly)
**[[Olanzapine]] 2.5-5 mg IM
**Avoid benzodiazepines (worsen delirium — exception: alcohol/benzo withdrawal)
*Review and discontinue deliriogenic medications when possible


==Disposition==
==Disposition==
*Admission
*Admit for workup and treatment of underlying cause
*ICU if hemodynamically unstable, severe agitation, or respiratory compromise


==See Also==
==See Also==
*[[Altered Mental Status]]
*[[Altered mental status]]
*[[Agitated delirium]]
*[[Dementia]]
*[[Acute psychosis]]
*[[Sundowning]]


==References==
==References==

Revisión actual - 09:26 22 mar 2026

Background

  • Acute disturbance of consciousness with fluctuating inattention and cognitive dysfunction
  • Caused by an underlying medical condition — NOT a primary psychiatric disorder
  • Extremely common: affects 10-30% of hospitalized elderly patients
  • Associated with increased mortality, prolonged hospitalization, and long-term cognitive decline
  • Key distinction from dementia: Delirium is acute (hours-days), fluctuating, with inattention as primary deficit; dementia is chronic (months-years) with memory as primary deficit

Clinical Features

  • Inattention — hallmark feature (cannot maintain or shift attention appropriately)
  • Fluctuating course throughout the day
  • Develops over hours to days (acute onset)
  • Subtypes:
    • Hyperactive: agitation, restlessness, hallucinations, combativeness (easier to diagnose)
    • Hypoactive: lethargy, decreased responsiveness, withdrawn (frequently missed — more common and more dangerous)
    • Mixed: alternating between hyperactive and hypoactive states

Common Causes (mnemonic: DELIRIUM)

  • Drugs (anticholinergics, opioids, benzodiazepines, steroids, polypharmacy)
  • Electrolyte abnormalities, Endocrine (thyroid, adrenal, glucose)
  • Lack of drugs (withdrawal from alcohol, benzodiazepines, opioids)
  • Infection (UTI, pneumonia, meningitis, sepsis)
  • Reduced sensory input (vision/hearing impairment, ICU environment)
  • Intracranial pathology (stroke, hemorrhage, mass, seizure)
  • Urinary retention, constipation (especially in elderly)
  • Myocardial/pulmonary (MI, PE, hypoxia, CHF)

Confusion Assessment Method (CAM)

  • Must have both features 1 AND 2 plus either 3 OR 4:
    1. Acute onset and/or fluctuating course
    2. Inattention
    3. Disorganized thinking
    4. Altered level of consciousness

Differential Diagnosis

Altered mental status

Diffuse brain dysfunction

Primary CNS disease or trauma

Psychiatric

General Psychiatric

Evaluation

  • Goal: identify and treat the underlying cause


AMS Workup

Common Orders


Consider Based on Clinical Situation

  • Blood and urine cultures
  • Ammonia level
  • Tylenol/Aspirin level
  • LP
  • Serum Osm
  • Coags
  • Cortisol
  • ABG/VBG
  • CO level
  • Minimum: glucose, BMP, CBC, urinalysis, ECG, CXR
  • Consider: LFTs, ammonia, TSH, blood cultures, lactate, urine toxicology screen
  • CT head if: focal neuro findings, fall/head trauma, anticoagulation, no clear cause identified
  • LP if meningitis/encephalitis suspected

Management

  • Treat the underlying cause — this is the definitive management
  • Non-pharmacologic measures first: reorientation, quiet environment, sleep-wake cycle preservation, mobilization, adequate hydration/nutrition, correct sensory deficits (glasses, hearing aids)
  • Pharmacologic (for severe hyperactive delirium with safety concerns):
    • Haloperidol 0.5-2 mg IV/IM (start low in elderly)
    • Olanzapine 2.5-5 mg IM
    • Avoid benzodiazepines (worsen delirium — exception: alcohol/benzo withdrawal)
  • Review and discontinue deliriogenic medications when possible

Disposition

  • Admit for workup and treatment of underlying cause
  • ICU if hemodynamically unstable, severe agitation, or respiratory compromise

See Also

References

Obtenido de «https://www.wikem.org/w/index.php?title=Delirium&oldid=389085»