DERILIUM

A clinical syndrome usually with acute onset, which involves abnormalities in thought and perception and fluctuating level of consciousness. It is caused by impaired brain function resulting from diffuse physiological change.

Causes

  • Infections e.g. malaria, trypanosomiasis, syphilis, meningitis, rabies, typhoid fever, HIV/AIDS
  • Pneumonia and urinary tract infections in elderly
  • Intoxication with or withdrawal from alcohol or other substances of dependence
  • Some medicines e.g. anticonvulsants and neuropsychiatric medications
  • Cerebral pathology e.g. head trauma, tumour
  • Severe anaemia, dehydration
  • Electrolyte imbalances, hyperglycemia

Clinical features

  • Acute onset of mental confusion with associated disorientation, developing within hours or a few days.
    Attention, concentration and memory for recent events is impaired
  • Reduced ability to think coherently: reasoning and problem solving are difficult or impossible
  • Illusions and hallucinations are common
  • Symptoms tend to fluctuate: patients feel better in the day and worse at night
  • Some patients may present with reduced activity and/or movement (hypoactive delirium)

Differential diagnosis

  • Acute psychosis

Investigations

  • Guided by history and physical examination: aim at identifying the cause
    NB: drug history is very important!
  • CBC, blood glucose, RDT, renal function and electrolytes

Management

Due to the complexity of underlying conditions, patients with acute confusional state should be referred to hospital
for appropriate management and investigation.

  • Identify and treat the cause such as substance and alcohol use disorders, diabetes, head injury or
    infections e.g. malaria, UTI, pneumonia in older people

Supportive treatment

  • Ensure hydration, control of fever, safe and quiet environment, constant monitoring
  • Withhold any unnecessary medicines, keep the use of sedatives and antipsychotics to the
    minimum necessary

If patient is agitated and acutely disturbed

  • Haloperidol 5 mg IM: repeat after 60 min if necessary
    • Continue with haloperidol 1.25-5 mg every 8 to 12 hours
  • Or chlorpromazine 25-50 mg every 8-12 hours
    (IM or oral)
  • Trifluoperazine 5-10 mg every 12 hours
  • If patient is extremely agitated
    • Diazepam 5-10 mg slow IV or rectal
      • repeat after 10-15 minutes if necessary
      • then oral diazepam 5-15 mg at night

    Prevention

    • Early diagnosis and treatment of underlying cause