Delirium

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Clinical Description

Sudden onset of confusion often accompanied by impairment of consciousness often caused by underlying organic conditions {e.g., infections) and usually reversible.

Clinical Features

SIGNS AND SYMPTOMS

  • Confusion
  • Fluctuating level of consciousness
  • Disorientation
  • Agitation / psychomotor retardation
  • Perceptual disturbances e.g., illusions, hallucinations
  • Fever, headache, sweating or other physical symptoms
  • delusions
  • Autonomic instability
  • Mood changes

INVESTIGATIONS

Look for underlying causes:

  • Systemic and CNS infections
  • Hypoxia
  • Hypo- or hyperglycemia
  • Urinary tract infections
  • Drugs
  • Alcohol intoxication or withdrawal
  • Post-convulsion phase in epilepsy
  • Head trauma
  • Subdural hematoma
  • Stroke etc.

Full physical examination including vital signs;

  • Full blood count
  • Urine/ Blood glucose test
  • Blood film or rapid diagnostic test for malaria
  • Consider LP for CSF analysis if suspect meningitis or encephalitis
  • Advisable to determine HIV serostatus
  • Syphilis

Treatment

NON-PHARMACOLOGICAL

  • Nurse the patient in calm, quiet and well-lit environment with frequent reassurance and orientation

PHARMACOLOGICAL 

  • The aim of treatment is to identify and treat the underlying organic cause. Psychotropic medications are supportive.
  • For behavioral disturbances or aggression give short course of low dose of antipsychotic medications, preferably orally
    • 1st line: Haloperidol 0.5 – 5mg 12 hourly or Risperidone 0.5 mg – 3 mg 12 hourly. If unavailable Chlorpromazine 50 - 100mg 12 hourly for 7 days or until agitation / confusion resolves
    • If the patient is refusing oral medications, use Haloperidol 2.5 - 5mg IM 12 hourly or Chlorpromazine 50 - 100mg IM 12 hourly if unavailable until sufficiently improved to accept medications orally
    • Avoid the use of diazepam / other benzodiazepines unless if history is suggestive of alcohol withdrawal, please refer to alcohol section for scheduling of benzodiazepines in alcohol withdrawal.
  • Note: Delirium is a medical emergency. All delirious patients must be admitted and investigated appropriately. Intravenous or high dose Diazepam can cause respiratory depression/ distress
  • If agitation is severe review the patient regularly
  • Once symptoms have resolved, stop antipsychotics and arrange review in 5- 7 days' time to ensure patient remained stable

REFFERAL CRITERIA

For referral 

  • Decreasing level of consciousness
  • Worsening physical health
  • Investigations required not available at health facility