The authors’ observations
A thorough history from the patient and caregivers, including the time course of mental status changes, new medication use, and history of medical and psychiatric disorders—especially depression and dementia—are important to obtain, especially early in the evaluation.
Although Mr. L’s irritability, delusions, and psychomotor slowing could be signs of psychotic depression, his fluctuating mental status, disorientation, poor attention, and impaired concentration suggest delirium (Table 3).4,7 This diagnosis is supported by the fact that Mr. L’s symptoms emerged after orthopedic surgery. Delirium after orthopedic surgery is common among older patients.8 Contributing and perpetuating factors in Mr. L’s case may have included postoperative complications, hypokalemia (hyperaldosteronism), medications (prednisone, digoxin, and olanzapine), and environmental unfamiliarity during hospitalization. A delirium diagnosis should be based on a high index of suspicion and a careful clinical assessment rather than diagnostic tests.
Table 3
Deconstructing delirium
| Defining characteristics |
| Confusional state of fluctuating course |
| Acute or subacute onset |
| Inattention |
| Disorganized thinking |
| Alteration and fluctuation of level of consciousness |
| Other characteristics |
| Cognitive: Memory impairment, perseveration |
| Motor: Hyperactive, hypoactive, mixed |
| Psychiatric: Thought disorganization, mood changes, delusions, hallucinations |
| Etiologies* |
| Predisposing factors: Age, functional status (ie, immobility), nutritional status (ie, dehydration), sensory impairment, medical conditions, psychiatric conditions (ie, dementia, TBI), medications, illicit drugs |
| Precipitating factors: Acute neurologic conditions (ie, stroke), intercurrent illnesses (ie, infections, hypoxia, anemia), surgery, environmental factors (ie, ICU, restraints, pain), illicit drugs (alcohol withdrawal), medications (ie, polypharmacy, anticholinergics), sleep depravation |
| *Usually >1 etiology ICU: intensive care unit; TBI: traumatic brain injury Source: References 4,7 |
OUTCOME: Return home
Mr. L’s confusion and delusional jealousy decrease over time, as do his disorientation and inattention, as evidenced by improvement on MMSE scores. His last MMSE score is 27/30, failing mostly in attention and recall.
After sustained improvement in cognition and behavior, Mr. L is discharged home on haloperidol and the remainder of his nonpsychiatric medications with outpatient medical and psychiatric follow-up. Over several months, he continues to show improvement and haloperidol is discontinued.
The authors’ observations
Delirium treatment should focus on prompt identification and management of precipitating and contributing factors.7 Antipsychotics are considered first-line treatment for patients with delirium, agitation, or psychosis who pose a risk to themselves or others. Benzodiazepines should be avoided in older patients unless symptoms are secondary to CNS-depressant withdrawal (ie, alcohol, benzodiazepines).9
Although there are no-FDA approved medications for delirium, haloperidol has been widely studied and used for treatment of agitation and psychosis in delirium. There is no evidence that low-dose haloperidol is any less effective than olanzapine or risperidone, or is more likely to cause adverse drug effects such as extrapyramidal syndrome.10 Antipsychotic use in a confused or agitated dementia patient increases risk of mortality compared with dementia patients who do not receive antipsychotics.11 The use of typical or atypical antipsychotics for delirium should be guided by the patient’s characteristics, such as cardiovascular status and presence or absence of underlying dementia. Atypical antipsychotics should be used carefully because—as in Mr. L’s case—anticholinergic side effects of medications such as olanzapine could worsen delirium.5 Once delirium has resolved, antipsychotics should be tapered and discontinued.
Other components of delirium treatment and prevention include:
- reorientation (verbally, with clocks, calendars, etc.)
- safe ambulation
- adequate sleep, food, and fluid intake
- adaptive equipment for vision and hearing impairment
- adequate management of pain and other comorbidities.12
Related Resources
- Khan RA, Kahn D, Bourgeois JA. Delirium: sifting through the confusion. Curr Psychiatry Rep. 2009;11(3):226-234.
- Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis, and treatment. Crit Care Clin. 2008;24:657-722.
- Young J, Inouye SK. Delirium in older people. BMJ. 2007;334(7598):842-846.
Drug Brand Names
- Amantadine • Symmetrel
- Amitriptyline • Elavil
- Aripiprazole • Abilify
- Atenolol • Tenormin
- Atropine • AtroPen
- Benztropine • Cogentin
- Cimetidine • Tagamet
- Clozapine • Clozaril
- Digoxin • Lanoxicaps, Lanoxin
- Glyburide • DiaBeta, Micronase
- Haloperidol • Haldol
- Levodopa/carbidopa • Parcopa, Sinemet
- Lisinopril • Prinivil, Zestril
- Lorazepam • Ativan
- Meperidine • Demerol
- Mirtazapine • Remeron
- Olanzapine • Zyprexa
- Omeprazole • Prilosec
- Oxybutynin • Ditropan
- Pergolide • Permax
- Phenytoin • Dilantin, Phenytek
- Prednisolone • Orapred, Prelone, others
- Prednisone • Deltasone, Meticorten
- Pyridostigmine • Mestinon
- Ranitidine • Zantac
- Risperidone • Risperdal
- Selegiline • Eldepryl, Zelapar
- Spironolactone • Aldactone
- Tamsulosin • Flomax
- Thioridazine • Mellaril
- Trazodone • Desyrel
- Warfarin • Coumadin
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.