Obtaining a thorough history is very important for diagnosis of this condition as there are no medical investigations that can diagnose delirium. Delirious patients are often confused and unable to provide accurate information so the history should be obtained from relatives and caregivers. Some of the symptoms that would be mentioned are disorientation, difficulty is maintaining concentration, shifting attention, illusions, reversal in sleep-wake cycle and hallucinations. These symptoms are usually worse at night and show improvement during the day. Other neurological symptoms that could be reported are motor abnormalities, uremia, tremors, dysarthria and dysphagia [6].
Elderly patients who present with symptoms of delirium usually have an underlying illness precipitating it.

• Fever

  All potential fever or delirium causes were evaluated. Following discontinuation of dexmedetomidine, her fever, agitation and delirium ceased. We depict the first known case of dexmedetomidine causing high fevers and delirium. [ncbi.nlm.nih.gov]

  […] noun mass noun 1 An acutely disturbed state of mind characterized by restlessness, illusions, and incoherence, occurring in intoxication, fever, and other disorders. [en.oxforddictionaries.com]

  […] usually accompanied by disordered speech and hallucinations 2 : frenzied excitement he would stride about his room in a delirium of joy — Thomas Wolfe a crowd in a state of delirium Synonyms for delirium Synonyms agitation, deliriousness, distraction, fever [merriam-webster.com]

  They were seized with fever and delirium, and this obstacle, in their minds, became material. No doubt as to who it was—the War Lord in a state bordering on delirium. [thesaurus.com]

• Epilepsy

  Some of the most common causes of delirium include: Infection of the bladder, chest or brain Fever Medication side effect Dehydration Liver or kidney problems Cessation of drug or alcohol use Major surgery Epilepsy Terminal illness Treatment If a person [news-medical.net]

  […] prescription medicine alcohol poisoning or alcohol withdrawal taking drugs carbon monoxide poisoning – especially if other people you live with become unwell a severe asthma attack or other problems with the lungs or heart certain types of seizures caused by epilepsy [nhs.uk]

  The IL-1beta system in epilepsy-associated malformations of cortical development. Neurobiol Dis 2006;24:128–143. [doi.org]

  Non-convulsive epilepsy. Charles Bonnet syndrome. Investigations[1, 5] These should be guided by the clinical presentation and are aimed at identifying an underlying cause of the delirium. [patient.info]

• Unconsciousness

  The neurologic status characterized by the occurrence of a loss of the ability to perceive and respond Applies To Drowsiness Semicoma Unconsciousness Somnolence Stupor ICD-9-CM Volume 2 Index entries containing back-references to 780.09 : [icd9data.com]

  This symptom usually fluctuates throughout the day and can range from having mild difficulty in sustaining attention or focusing, to excessive drowsiness to the point of appearing unconscious. [healthhub.sg]

  Then, when your mind is very relaxed, what was unconscious becomes conscious. Gayle: On the surface, there’s a very big leap between your first two books. [amazon.com]

  They can hold the patient's hand or talk to them, which can help orient them, even if they appear unconscious on a ventilator. But now, hospitals are keeping patients isolated and away from family to contain the spread of coronavirus. [edition.cnn.com]

  “The idea has long been: ‘We want to keep you unconscious so you don’t suffer.’” Ely said. “We thought we were ‘protecting’ patients.” [statnews.com]

• Swelling

  At autopsy, the skull was fractured with cerebral swelling, contusions, and subarachnoid hemorrhage. Death was due to blunt cranial trauma against a background of mixed drug toxicity. [ncbi.nlm.nih.gov]

  Normal/Magic Wasting Touch Normal/Magic Winter Whorl Normal/Magic Bolt Cross Rare/Unique Burrowing Blade Rare/Unique Conflagrating Path Rare/Unique Crushing Leap Rare/Unique Frozen Flume Rare/Unique Glaciator Rare/Unique Icicle Wreath Rare/Unique Jagged Swell [pathofexile.gamepedia.com]

  These include medicines that treat: Pain Sleep problems Mood disorders, such as anxiety and depression Allergies Asthma Swelling Parkinson's disease Spasms or convulsions Risk factors Any condition that results in a hospital stay increases the risk of [mayoclinic.org]

  Scalp or facial lacerations, bruising, swelling, and other signs of head trauma suggest traumatic brain injury. [merckmanuals.com]

• Pathologist

  The forensic pathologist should consider cocaine-induced excited delirium when an individual exhibits aggressive behavior, unexpected strength, and resistance to pain who dies suddenly. [ncbi.nlm.nih.gov]

  Interpretation of this test should be performed in the context of the patient's clinical history and other diagnostic tests by a qualified pathologist. [mayocliniclabs.com]

  […] she wouldn't let anyone in here to clean it for her. en Anxiety, depression, delirium en The following additional adverse reactions have been observed with Prometax transdermal patches: anxiety, delirium, pyrexia (common en Say Nina Molander is lead pathologist [sk.glosbe.com]

  […] gonadal) and germ cell neoplasia in situ (GCNIS) but not specific Virtually always positive (strong and diffuse) in seminomas; useful for discriminating from spermatocytic tumor Interpretation Membranous and cytoplasmic staining are expected Uses by pathologists [pathologyoutlines.com]

  All specimens were macroscopically examined by one pathologist (Tuomo Polvikoski), blind to all clinical data, using a standardized dissection and sampling protocol. [doi.org]

• Nausea

  In addition to its use for these indications olanzapine has also been used in the management of chemotherapy induced nausea and vomiting and otherwise difficult to control nausea and vomiting in palliative care settings. [ncbi.nlm.nih.gov]

  Certain medications used along with cancer treatment such as opioids (strong pain medication), steroids, medications used to prevent or treat nausea or allergies, appetite stimulants, or sleep medications. [cancer.org]

  There are several potential causes of these imbalances: Hypercalcemia, which is too much calcium in the blood Dehydration from not taking in enough fluids because of nausea, vomiting, or not being able to swallow comfortably. [cancer.net]

  We did not find any clear differences between the two groups in terms of duration of delirium ( MD -3.6, 95% CI -15.6 to 8.4), adverse events (nausea, RR 0.30, 95% CI 0.01 to 6.29), use of rescue medications ( RR 0.13, 95% CI 0.01 to 2.1), mortality [cochrane.org]

• Loss of Appetite

  The presence of loss of appetite for more than two weeks may be the key to a diagnosis of WE. [ncbi.nlm.nih.gov]

  […] of appetite Nausea, vomiting Nervousness, jumpiness, shakiness, palpitations (sensation of feeling the heart beat) Pale skin Rapid emotional changes Sweating, especially on the palms of the hands or the face Other symptoms that may occur: Chest pain [medlineplus.gov]

  Some of the symptoms and warning signs of teen drug abuse include reddened whites of eyes, paranoia, sleepiness, excessive happiness, seizures, memory loss, increased appetite, discolored fingertips, lips or teeth, and irritability. [medicinenet.com]

  […] of appetite, and disturbed sleep. [britannica.com]

• Abdominal Pain

  Are there any new physical symptoms — for example, chest or abdominal pain? The doctor will ask additional questions based on your responses and the person's symptoms and needs. [mayoclinic.org]

  pain, abdominal distention, history of cirrhosis Liver function tests; measurement of lipase level and ammonia levels Infection suspected Blood cultures, complete blood count, chest radiography, computed tomography, lumbar puncture, urinalysis with culture [aafp.org]

  The sufferer experiences palpitations, dry mouth, dilatation of the pupils, shortness of breath, sweating, abdominal pain, tightness in the throat, trembling, and dizziness. [britannica.com]

• Hypertension

  […] anxiety, nightmares), in a very few cases resulting in accidental injury or fatal outcomes en Other medically significant sequelae of overdose include delirium, convulsion, coma, possible neuroleptic malignant syndrome, respiratory depression, aspiration, hypertension [sk.glosbe.com]

  DTs is the most severe manifestation of alcohol withdrawal and clinical manifestations include agitation, global confusion, disorientation, hallucinations, fever, hypertension, diaphoresis, and autonomic hyperactivity (tachycardia and hypertension). [emedicine.medscape.com]

  In the multivariate analysis hypertension, smoking history, abnormal bilirubin level, epidural use and morphine were statistically significantly associated with delirium. [ncbi.nlm.nih.gov]

  […] discharge and higher nursing home placement rates PATHOPHYSIOLOGY complex and poorly understood altered cerebral blood flow numerous biomarkers e.g. s100beta protein, neuron specific enolase, ILs RISK-FACTORS Baseline age preexisting dementia history of hypertension [lifeinthefastlane.com]

  […] hemorrhage, tumour, seizure disorder, Parkinson’s) H ypoxia (anemia, cardiac failure, pulmonary embolus) D eficiencies (vitamin B 12, folic acid, thiamine) E ndocrinopathies (thyroid, glucose, parathyroid, adrenal) A cute vascular (shock, vasculitis, hypertensive [fammedref.org]

• Tachycardia

  Its importance cannot be overemphasized, for acute confusion is a far more common herald of the onset of physical illness in an older person than are, for example, fever, pain or tachycardia." 7 The elderly, especially the very old, are uniquely prone [doi.org]

  During withdrawal from alcohol, the loss of GABA-A receptor stimulation causes a reduction in chloride flux and is associated with tremors, diaphoresis, tachycardia, anxiety, and seizures. [emedicine.medscape.com]

  A focused assessment is often needed, with particular attention paid to vital signs (hypo/hypertension, fever/hypothermia, tachycardia, tachypnea), the state of hydration (mucus membranes, skin turgor), skin condition (decubiti, cellulitis) and potential [clinicaladvisor.com]

  […] symptoms of hypo- or hyperglycemia Measurement of thyroid-stimulating hormone and serum glucose levels; measurement of serum cortisol level or adrenocorticotropic hormone stimulation test Environmental exposure: shivering, hypo- or hypertension, brady- or tachycardia [aafp.org]

• Sweating

  In chronic alcoholism, attacks of delirium tremens (DTs), marked by hallucinations, sweating, trembling, and anxiety, may persist for several days. [onlinerecnik.com]

  She is said to smell of sweat, late nights, sour wine, and old leather. Her sigil in the galleries of the other Endless is a multicolored, abstract swirl. [sandman.wikia.com]

  […] en They braved many hardships, such as recurrent attacks of malaria, with its symptoms of shivering, sweating, and delirium. sk Tu ide o česť nášho kráľovstva en In patients with influenza who were receiving Tamiflu, there have been postmarketing reports [sk.glosbe.com]

  Fatigue Headache Insomnia (difficulty falling and staying asleep) Irritability or excitability Loss of appetite Nausea, vomiting Nervousness, jumpiness, shakiness, palpitations (sensation of feeling the heart beat) Pale skin Rapid emotional changes Sweating [medlineplus.gov]

• Distractibility

  Unfocused and distracted selectivity results in chaotic cognitions and the typical symptoms of delirium. Several terms are used to describe the deficits of delirium; rarely are they defined, and often they are used loosely and inconsistently. [dictionary.cambridge.org]

  To save this word, you'll need to log in. a state of wildly excited activity or emotion shoppers running around in a delirium the day before Christmas agitation, deliriousness, distraction, fever, feverishness, flap, frenzy, furor, furore, fury, hysteria [merriam-webster.com]

  The essestial features of delirium include: Acute onset (hours/days) and a fluctuating course Inattention or distraction Disorganized thinking or a altered level of consciousness Treatment of delirium, like dementia, is managed both pharmacologically [hopkinsmedicine.org]

  She is scatterbrained and easily distracted; she often forgets the thread of her conversations, and comes out with offbeat and seemingly inconsequential observations. [sandman.wikia.com]

  […] functions.Typical symptoms include: Reduced perceptional and sensory abilities Abrupt changes in movement (hyperactivity or slowness) Sleep cycle changes (sleeping more, drowsiness) Confusion about whereabouts and time Lack of concentration (easily distracted [verywellmind.com]

• Withdrawn

  Autumn 2019 The scenario is distressing: Your elderly parent is hospitalized and becomes confused, withdrawn, anxious, and not himself. [hms.harvard.edu]

  They may become agitated and restless or withdrawn. Delirium can be very upsetting for family members to watch. If your loved one develops signs of delirium, let his or her healthcare provider know right away. [saintlukeskc.org]

  Sedatives can worsen delirium and should only be given in cases where: The patients is extremely anxious The patient has suddenly withdrawn from alcohol or drugs When the patient is at risk of endangering themselves or others In order to calm someone [news-medical.net]

  Being withdrawn, with little or no activity or little response to the environment. Poor Thinking Skills (Cognitive Impairment) Poor memory, particularly of recent events. Loss of the ability to stay focused on a topic or even on play. [nationwidechildrens.org]

• Visual Hallucination

  Although she exhibited transient visual hallucinations during the delirium, she had no overt dementia. She developed no core clinical features of DLB and died of pneumonia at the age of 90 years. [ncbi.nlm.nih.gov]

  While visual hallucinations can occur in patients with primary psychiatric illnesses such as schizophrenia, they are much less common than auditory hallucinations. [aafp.org]

• Mood Swings

  swings that vary from scared and anxious to depressed or irritable Confusion that worsens in the evenings Causes and risks associated with delirium Delirium is fairly common among hospitalized patients, with around 1 in 10 having a period of delirium [news-medical.net]

  Hyperactive Delirium This type of delirium tends to involve restlessness, agitation, rapid mood swings or hallucinations. It may result in a patient refusing to cooperate with a caregiver. [verywellmind.com]

  You may also move more slowly or quickly than usual, and experience mood swings. [healthline.com]

• Aggressive Behavior

  The forensic pathologist should consider cocaine-induced excited delirium when an individual exhibits aggressive behavior, unexpected strength, and resistance to pain who dies suddenly. [ncbi.nlm.nih.gov]

  […] issues Escalating physically aggressive behavior or threats of violence Persistent danger to self or others Table 9. [aafp.org]

  Noradrenergic changes, aggressive behavior, and cognition in patients with dementia. Biol. Psychiatry 51, 407–416. doi: 10.1016/s0006-3223(01)01235-5 CrossRef Full Text | Google Scholar Mc Donnell, S., and Timmins, F. (2012). [frontiersin.org]

• Confusion

  Postoperative delirium negatively impacts ... read more Blood Test May Help Predict Confusion After Surgery Jan. 11, 2017 — Many people experience an extended period of confusion when they awake after surgery. [sciencedaily.com]

  (n=41) and/or (3) were identified as confused by nursing staff (n=52) and/or (4) had ‘confusion’ documented in the case notes (n=29). [doi.org]

  Confusion, introduced by French workers during the second half of the century, referred to a syndrome wider than (but including) delirium. It emphasized chaotic thinking and cognitive failure. [ncbi.nlm.nih.gov]

  Main navigation Sudden confusion (delirium) describes a state of sudden confusion and changes in a person’s behaviour and alertness. [nidirect.gov.uk]

• Agitation

  Valproic acid was effective in treatment of agitation and well tolerated. [ncbi.nlm.nih.gov]

  Wake Up and Breathe Flowchart Choice of Analgesia and Sedation  Richmond Agitation-Sedation Scale (RASS) Riker Sedation-Agitation Scale (SAS) Level of Arousal Assessment Conversions MDCalc iOS and Android app Protocol for Management of Pain, Agitation [icudelirium.org]

• Hyperactivity

  MAIN OUTCOMES AND MEASURES: Delirium was detected using the Confusion Assessment Method and categorized in hypoactive, hyperactive, or mixed delirium. [ncbi.nlm.nih.gov]

  Two subtypes have been described—hyperactive and hypoactive—based on differential psychomotor features. [accessmedicine.mhmedical.com]

  At times, patients are restless Patients are restless and physically hyperactive The longer delirium lasts, the higher the impact Delirium detection is complicated and confusing. [prolira.com]

• Excitement

  Excited delirium denotes a life-threatening medical condition characterized by the acute onset of agitated and violent behavior that often results in a sudden and unexplained death. [ncbi.nlm.nih.gov]

  ‘I ended up getting a digital keyboard, which was so amazing to me - excitement to the point of delirium.’ ‘The smell of incense filled the room and transported me, in my delirium, back to my youth as a Miami altar boy.’ [en.oxforddictionaries.com]

  Delirium Candles are meant to elicit a calculable response when experienced; a state of uncontrolled excitement or emotion. Intoxicating, familiar, mysterious, arresting, unconventional, magnetic, hypnotic. [candledelirium.com]

  […] de·lir·i·um | \ di-ˈlir-ē-əm \ 1 : an acute (see acute sense 1a(2) ) mental disturbance characterized by confused thinking and disrupted attention usually accompanied by disordered speech and hallucinations 2 : frenzied excitement he would stride about [merriam-webster.com]

• Tremor

  Minor alcohol withdrawal is characterized by tremor, anxiety, nausea, vomiting, and insomnia. [emedicine.medscape.com]

  At 11-month follow-up, only mild executive dysfunction and persistent right postural tremor was noted, MRI showed partial regression of subcortical and juxtacortical lesions. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article [ncbi.nlm.nih.gov]

  Symptoms may get worse quickly, and can include: Delirium, which is sudden severe confusion Body tremors Changes in mental function Agitation, irritability Deep sleep that lasts for a day or longer Excitement or fear Hallucinations (seeing or feeling [medlineplus.gov]

  Alcoholic delirium—called delirium tremens because of the characteristic tremor—is a result not merely of excessive consumption of alcohol but of a complicating exhaustion, lack of food, and dehydration; prior to the outbreak of delirium, the patient [britannica.com]

  […] quiet Be unusually aggressive Use inappropriate words Be unable to pay attention or follow directions See or hear things that are not there Be unaware of their surroundings Act differently than normal Have memory problems Undergo emotional changes May tremor [centrahealth.com]

There is no one test for diagnosing delirium, but there are numerous tests that could be useful for diagnosing precipitating symptoms. Blood tests like complete blood count, sedimentation rate and bacterial/viral culture are used to rule out underlying infections. Blood tests also help to detect electrolyte derangement and problems with glucose metabolism. They are useful to determine renal, hepatic and thyroid function. Urine tests are also used to check for infections and toxicology screening to check for drugs and poisons. HIV tests and tests for vitamin B12 and thiamine are also carried out.

Imaging studies are also done to check the structure of the brain and they include CT scans and MRI. Electroencephalogram (EEG) is also useful in delirium as it may also give an indication to the cause of the delirium based on the wave patterns. A chest radiograph also is used diagnose congestive heart failure or pneumonia.

Other tests like lumbar puncture is done when a CNS infection is suspected. Pulse oximetry to diagnose hypoxia and ECG if an arrhythmia or ischemia is suspected as the underlying cause [7].

The most important step in treatment is to identify the underlying cause and eliminate it. The mainstay of delirium treatment is supportive therapy and drug therapy.
Supportive therapy involves maintaining normal hydration as nutrition levels. Thiamine should be given to patients who are undergoing alcohol withdrawal. It is important for the patient’s environment to be quiet, stable and well-lit.

Memory cues like clocks, family photos and calendars are useful in reorientation. Reorientation should be reinforced by family members. Sensory defects should be corrected as required. It is important to avoid physical restraints as it only heightens the patient’s perception of problems and could lead to combative behaviour. It is important that these patients are closely monitored and never left alone [8].

Medication should be considered in patients who cause injuries to themselves or others. Medications used include neuroleptics like haloperidol and risperidone and short-acting sedatives like lorazepam. Sedatives are used in patients withdrawing from alcohol or sedative hypnotics [9].

There are mortality rates of up to 26% in patients admitted with delirium. Patients who develop delirium in the hospital have a mortality rate of up to 76%. For post-operative and elderly patients, delirium could lead to extended hospital stay, increased complications, extra costs and disability [5].

Delirium is often a result of conditions that impair the supply of oxygen and other substances in the brain. Some of the causes include infections like urinary tract infections (UTI) and pneumonia, dehydration, metabolic derangements, withdrawal symptoms from alcohol and drugs, drug toxicity, chemicals, seizures, head injuries, surgeries and chronic illnesses amongst others [2].

It is a fairly common condition and is seen is about 14 to 56% of hospitalized elderly patients. Up to 30% of cases develop after admission and 40% of patients admitted to intensive care units develop delirium. The prevalence of post-surgical delirium is also high with as high as 40% of patients developing delirium after orthopaedic surgery. Delirium is also very common in nursing home residents and as much as 80% of people develop delirium near death. It has no race or sex predilection [3].

There are 3 recognizable delirium types based on the state of arousal. Hyperactive delirium is associated with intoxication with some stimulant drugs or withdrawal from alcohol. Hypoactive delirium is seen in patients with hepatic encephalopathy. In the third type, mixed delirium, there is usually sedation during the day and at night, patients develop behavioural problems.

There has been no clear understanding of the mechanism by which delirium occurs as it results from various psychological and physical insults. The widely accepted hypothesis is that there are multiple neurotransmitter abnormalities and reversible impairment of the cerebral oxidative mechanism. Observations such as reduced cholinesterase activity and increased dopaminergic activity support the hypothesis of neurotransmitter abnormalities [4].

There is no specific prevention for delirium as it is a consequence of various other conditions. The preventive measures implemented for specific conditions which cause disturbance in cerebral function can indirectly prevent delirium.

Delirium is a syndrome that results from multiple causes that have similar type of symptoms. Early diagnosis and resolution of symptoms are important to avoid morbidity and mortality. It is a medical emergency and should be treated as one [1].

• Definition: Delirium is a sudden change in brain function that results when there is an interruption in the sending and receiving of signals in the brain. It is characterised by hallucinations and decreased awareness.
• Cause: Delirium is often seen in patients who have prolonged stay in the hospital, especially the intensive care unit. It is caused by a problem with neurotransmitter function and a problem with oxygen mechanism in the brain. Some of the things that could lead to this include infections, drugs and drug withdrawal, seizures, head injuries, surgeries and long term illnesses.
• Symptoms: Some of symptoms to look out for include change in mood, difficulty concentrating, hallucinations, confusion, change in sleep pattern, movement disorders and incontinence.
• Diagnosis: This is usually made based on the symptoms and sign. Some tests may however be needed to check for the possible causes. Blood tests will check for infection, glucose level, electrolyte level, and the kidney, liver and thyroid functions. Imaging studies may also be carried out on the brain to check the structure and activity.
• Treatment: The treatment is usually supportive. The family members and caregivers are essential for this step. It involves helping the patient remember and slowly integrate him into his normal life. Fluid and nutrition are given and drugs are used in some special cases [10].

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5thed. Washington, DC: American Psychiatric Association; 2013.
2. de Rooij SE, van Munster BC, Korevaar JC, Levi M. Cytokines and acute phase response in delirium. J Psychosom Res. May 2007;62(5):521-5.
3. Ebersoldt M, Sharshar T, Annane D. Sepsis-associated delirium. Intensive Care Med. Jun 2007;33(6):941-50.
4. Limosin F, Loze JY, Boni C, et al. The A9 allele of the dopamine transporter gene increases the risk of visual hallucinations during alcohol withdrawal in alcohol-dependent women. Neurosci Lett. May 20 2004;362(2):91-4.
5. Folstein MF, Folstein SE, McGugh PR. "Mini- Mental State". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. Nov. 1975;12(3):189-98.
6. Cole M, McCusker J, Dendukuri N, Han L. The prognostic significance of subsyndromal delirium in elderly medical inpatients. J Am Geriatr Soc. Jun 2003;51(6):754-60.
7. Van Rompaey B, Elseviers M M, Van Drom W, Fromont V, Jorens P G. The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients.Critical Care. 2012;16.
8. Anderson CP, Ngo LH, Marcantonio ER. Complications in Postacute Care Are Associated with Persistent Delirium. J Am Geriatr Soc. May 30 2012
9. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med. 2001;27:859-864.
10. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. Mar 20 1996;275(11):852-7.