Epidemiology

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Etiology

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Risk factors

• Advanced age
• Neurologic disorder (e.g. dementia, stroke)
• Sensory impairment (e.g. hearing loss)
• Sleep disruption
• Immobilization

Precipitating causes

• Drugs (eg, narcotics, sedatives, antihistamines, muscle relaxers, polypharmacy)
• Infections (eg, pneumonia, urinary tract infection, meningitis)
• Electrolyte disturbances (eg, hyponatremia, hypercalcemia)
• Metabolic derangements (eg, volume depletion, vitamin B12 deficiency, hyperglycemia)
• Systemic illnesses (eg, congestive heart failure, hepatic failure, malignancy)
• CNS conditions (eg, seizure, stroke, head injury, subdural hematoma)

Pathophysiology

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Clinical features

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Diagnostics

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• Differential diagnostics
  • Mania: cognition is intact; not disoriented; treated with lithium

Treatment

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• Polypharmacy/psychoactive drug avoidance
• Sleep facilitation: bright day/dim night lighting
• Visual/hearing aids
• Mobilization: out of bed, restraint avoidance

Treatment of agitation in delirium

• Agitation should initially be managed with nonpharmacologic strategies.
  • Avoid physical restraints as much as possible in older patients with delirium, as they can worsen distress and agitation, as well as contribute to preventable injuries.
• Pharmacotherapy
  • Antipsychotics
    • Typical antipsychotics: e.g., haloperidol (most commonly used)
    • Atypical antipsychotic options
      • Risperidone
      • Olanzapine

Warning

• Avoid antipsychotics in patients with underlying alcohol withdrawal or benzodiazepine withdrawal (due to the risk of seizures) and in patients at high risk for QTc prolongation (due to the risk of torsades de pointes).
• Benzodiazepines are deliriogenic. Do not treat delirious patients with benzodiazepines unless the delirium is due to alcohol or benzodiazepine withdrawal.