Symptoms

             Typical symptoms of delirium include:

• Sudden onset over hours to days
• Slurred speech and language difficulties, talking that does not make sense
• Changes in feeling (sensation) and perception
• Decreased attention, concentration, and environmental awareness; usually more alert in the morning than at night; in and out of consciousness
• Changes in movement (for example, the person may move slowly or become very restless)
• Changes in sleep patterns, such as reversed sleep-wake cycles
• Confusion and disorientation, not being aware of correct time or place
• Memory loss, including decreased short-term memory and recall
• Disorganized thinking
• Emotional or personality changes, with frequent changes in moods, including anger, agitation, anxiety, apathy, depression, fear, euphoria, irritability, suspicion

Diagnosis

Diagnosis of delirium is made on the basis of careful observation and mental status testing. To evaluate thinking and specifically someone’s attention span, doctors may use a simple set of tests and standardized questions similar to those used to diagnose dementia. These are examples of typical questions:  

• Perform a simple math calculation
• Spell a short word backward
• Repeat a series of four or five numbers, in order and then in reverse order
• Name the days of the week backward

The following tests may be used by healthcare professionals to determine causes of delirium:

• Neurological exams, including tests of feeling (sensation), thinking (cognitive function), and motor function
• Psychological tests evaluating for depression or acute psychiatric syndromes
• Blood tests (such as a comprehensive metabolic panel or toxicology screen)

Other tests based on the person’s symptoms may include:

• Chest x-ray
• Urinalysis 
• Electrocardiogram

Causes

• Drugs, including any new medications, increased dosages, drug interactions, over-the-counter drugs, alcohol, etc.
• Electrolyte disturbances, especially dehydration and thyroid problems.
• Lack of drugs, such as when long-term sedatives (including alcohol and sleeping pills) are stopped or when pain killers are not being given adequately.
• Infection, commonly urinary or respiratory tract infection.
• Reduced sensory input, which happens when vision or hearing are poor.
• Intracranial (referring to processes within the skull) such as a brain infection, hemorrhage, stroke, or tumor (rare).
• Urinary problems or intestinal problems, such as constipation or inability to urinate.
• Myocardial (heart) and lungs, such as heart attack, problems with heart rhythm (arrhythmia), worsening of heart failure, or chronic obstructive lung disease. 

Prevention

To reduce the risk of delirium or help someone who develops symptoms of delirium, the environment must be managed so that the person feels oriented. Avoid moving them from one room or space to another unnecessarily and try to keep staff changes to a minimum if possible. Encourage regular schedules for meals, tests, exercise, and monitoring. Family members, close friends, or even paid assistants should try to stay with the person in order to reduce the fear and anxiety often seen in delirium.    

If possible, attempt to treat sleep problems without medications. Try warm milk or herbal tea, music, and massage in the evening, and keep nighttime noise to a minimum. Research has shown that these steps are more effective than medications and lead to better sleep quality. Dim lights left on at night can help decrease delusions or hallucinations.

1. Help orient cognitively impaired patients in time and place (using clocks, calendars, windows, blackboards with healthcare providers’ names).
2. Get patients up and about as soon as possible.
3. Minimize the use of psychoactive (mood) medications by using non-drug therapies whenever possible.
4. Implement a healthy sleep-wake cycle using windows, bright morning light, reduction in night noises, etc.
5. Improve sensory input and communication using appropriate aids, especially good eyeglasses, hearing aids (check the batteries!), and dentures if needed.
6. Give plenty of fluids, and make sure patients don’t get dehydrated. 

Care for older people with delirium involves special hospital care with careful attention to medical, environmental, and social situations. People with delirium are particularly vulnerable to medical complications such as falls, dehydration, malnutrition, pressure ulcers, joint stiffness, constipation, or wetting the bed. This is because they are not able to move around much or because of reduced consciousness. These complications often result in poor outcomes.

To reduce the risk of delirium, or to help someone who develops symptoms of delirium, the environment must be managed so that the person feels oriented. Avoid moving them from one room or space to another unnecessarily and try to keep staff changes to a minimum if possible.