Clinical Features Key Points

• Delirium is characterized by an acute change from usual function and cognition.

• Level of consciousness varies, often dramatically, in patients with delirium.

• Delirium may be hyperactive, hypoactive, or mixed.

• Delirium is often overlooked or misdiagnosed.

• Delirium worsens prognosis and increases length of stay and likelihood of nursing home placement.

Delirium is an acute disorder of global cognitive function involving attention, consciousness, orientation, memory, sensory perception, executive function, and behavior. Misperceptions of any of the senses may occur, but auditory and visual disturbances manifesting as suggestible hallucinations or illusions are common. For example, the delirious patient may interpret spots on the floor tiles as bugs or the sound of the wind as whispering. Delirious patients have abnormal visual perception compared to cognitively normal and demented patients that is independent of the severity of cognitive impairment (Brown et al., 2009).

Delirium cases can be grouped into hyperactive, hypoac-tive, and mixed subtypes on the basis of psychomotor behavior (Meagher et al., 2008). It has been suggested that the hypoactive subtype is more often seen in elderly persons and with delirium caused by hypoxia, metabolic abnormality, and anticholinergic drugs, whereas the hyperactive subtype is more common in substance intoxication and withdrawal states. Cognitive impairment and generalized slowing of the electroencephalogram (EEG) are similar in hypoactive and hyperactive subtypes.

Delirium can occur at any age, although advanced age is an independent risk factor. Rather than considering chronologic age in assessing risk, a family physician may best consider biologic age and frailty.

Delirium is often overlooked or misdiagnosed. This lack of diagnostic clarity is concerning given that, independent of other variables, delirium worsens prognosis (Fong et al., 2009; McAvay et al., 2006), often leading to chronic decreased function and cognition. Only 15% of delirious hospitalized patients will regain their baseline function by discharge, and less than half will return to prior function at 6 months (Khan et al., 2009). Delirium increases hospital length of stay by 5 to 10 days (Siddiqi et al., 2006), as well as the likelihood of nursing home placement (Inouye et al., 1998). Finally, mortality increases by 10% to 37% in hospitalized elderly patients (McCusker et al., 2002; Siddiqi et al., 2006). Approximately 40% of patients with delirium during hospitalization who survive to discharge will die within 1 year (Inouye, 2006).

Delirium prevalence and incidence vary greatly across settings of care and populations served. From 10% to 15% of hospitalized elderly patients have delirium on admission, and another 5% to 10% develop it during their stay. More than half of long-term care residents will exhibit delirium on hospital admission. Postsurgical patients (e.g., hip fracture, cardiac surgery) and elderly patients cared for in an intensive care unit (ICU) are at particularly high risk (Khan et al., 2009).

Etiology

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