Delirious

It has been 2 weeks since my last blog. My wife and I spent Labor Day weekend in Newport,RI having the joy of watching our youngest niece get married. We were deliriously proud and happy!

Delirium is an acute condition of confusion. The causes of delirium include medications, infections, vascular problems, metabolic disorders, endocrine diseases, and toxins. When an elderly patient arrives in the ER with a "change in mental status", the hunt for the cause of their delirium begins.

My beloved wife has had to deal with my own episodes of delirium. General anesthesia caused me to have paranoid delusions as I awoke in post-op. I told her that people were after me and had injured my abdomen. I had visual hallucinations induced by Dilaudid, a narcotic pain medication. I saw bunnies and giraffes in the patterns of the ceiling tiles. Another Dilaudid fueled delirium had me speaking French and not being aware of why my wife couldn't understand what I was saying.

Many prescription and non-prescription medication can lead to delirium. Benadryl, if taken in excess can cause confusional states. A mnemonic for diphenhydramine overdose is "red as a beet, dry as a bone, hot as a hen and mad as a hatter". As mentioned in a previous blog, mercury was used by hat makers to work the felt. The mercury, a neurotoxin, was absorbed through the skin and caused injury to the brain, thus "mad as a hatter". Drugs that have anticholinergic properties, narcotics (morphine, etc), benzodiazepines (valium, ativan, etc.) and many other medications can lead to delirium.

Alcohol can cause delirium when ingested and for habitual users as a symptom of withdrawal. Delirium tremens is the shaking and confusion seen in alcoholics as they withdraw. Street drugs such as ecstacy, LSD, GHB, PCP, ketamine and cocaine can all cause acute delirium.

Hyper and hypo: glycemia (blood sugar), natremia (sodium), calcemia (calcium), magnesemia, hypoxia (low oxygen), and hypercarbia (high carbon dioxide) are all potential causes of delirium. Liver failure, leading to elevated ammonia level,s and kidney failure, with resulting high urea levels, may both cause delirium as these toxic products of normal body functioning affect the brain.

Both overactive and underactive thyroid hormone levels may cause an altered mental state. Addison's disease (low levels of cortisol) and patients taking corticosteroids chronically, who cease taking these medication abruptly, may present as acute delirium. Malnutrition from anorexia, wasting diseases (such as cancer), and in chronic alcoholism often have deficiencies if vitamin B12, thiamine, folic acid, and niacin. These deficiencies may all lead to delirium.

Dehydration from lack of water intake in nursing home patients, heat exposed patients, and patients with water loss from vomiting and diarrhea may develop a change in mental functioning, i.e. delirium.

A very wise, part time ER doctor told me that when an elderly woman presented with a change in mental status, I should always check for a urinary tract infection. Any systemic infection from UTI's to pneumonia to skin and other soft tissues, may lead to delirium. Infections of the central nervous system (CNS) such as meningitis and encephalitis almost always cause alterations in consciousness.

Sensory and sleep deprivation and stress, as with a patient in a hospital ICU, may develop psychosis. Severe hypertension may cause hypertensive encephalopathy. Auto-immune diseases such as Lupus and vasculitis are potential causes of delirium. Certain forms on nonconvulsive seizures may present as acute delirium.

Whew! Do you get the picture. The work up of a patient with acute delirium is challenging. The medical description of delirium includes hyperactivity and hypoactivity. The patient may be agitated, even assaultive or lethargic. They often have altered wake and sleepy cycles. They may have perceptual deficits involving their hearing, vision, touch, etc. Symptoms of psychosis such as visual, auditory and olfactory hallucinations and delusions (false beliefs) are often present. Impaired memory is common.

Let's consider a few patients that I have recently treated in the ER. Joe is an alcoholic. He is in his 50's and is a life long abuser of alcohol. Food is eaten infrequently and of low nutritional value. He falls frequently. It is summer and he is often outdoors during the heat of the day. He presents with a temp of 103, pulse of 130, BP 160/90, shaky and very confused. He babbles about the aliens who are monitoring his thoughts. Infection, alcohol withdrawal, liver disease, malnutrition, hyperthermia, dehydration, electrolyte abnormalities, CNS injury ...

Mary arrives from the NH. The report says she is more confused than usual. Mary is a diabetic, has had a stroke that prevents her from walking, and has mild dementia. She has a low grade fever, is "picking the bugs" off of her clothes. She kicks and scratches the nurses as they try to take her vital signs and obtain blood and urine for testing. Infection, dehydration, CVA (stroke), low or high blood sugar, medication reaction ...

Jim is an obese diabetic with chronic bronchitis on prednisone. He has sleep apnea. He has been known to have a few drinks every day. His daughter found his medication bottles empty and a month out of date. His CPAP machine for his sleep apnea has cobwebs. Glucose abnormal, hypoxic, elevated CO2, low cortisol from not taking his prednisone, infection, alcohol elevated or withdrawal...

Susan is a 20 year old college student brought in by ambulance for acute psychosis. She is clearly having auditory and visual hallucinations. She responds to my questions with paranoid delusions. Is this schizophrenia or bipolar disorder with mania and psychosis? Before calling the psychiatrist, I have to medically clear her. Infection, metabolic disorder, drug use ...

A patient presenting with delirium is challenging for the ER staff. Information from family, EMS, friends, caretakers and prior records is invaluable. A thorough examination of the patient is crucial. Labs, imaging studies, and diagnostic procedures may all be utilized to arrive at the cause of the delirium. The treatment of delirium is to treat the underlying cause. Simple. NOT.