Delirium

Clinical Description

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

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

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

Complications and Referral Criteria

For referral

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