Sudden confusion (delirium)

Sudden confusion, medically referred to as delirium, is a serious neuropsychiatric syndrome characterized by an acute and fluctuating disturbance in attention, awareness, and cognition. It usually develops over a short period of time (hours to days) and is often associated with an underlying medical condition, substance intoxication or withdrawal, medication side effects, or acute organ dysfunction. Delirium is considered a medical emergency, especially in older adults, as it is frequently linked with increased morbidity, mortality, prolonged hospitalization, and long-term cognitive decline if not addressed promptly.

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Causes of Sudden Confusion (Delirium)

Delirium is multifactorial, and common underlying causes include:

• Infections: Urinary tract infections, pneumonia, sepsis, meningitis, and encephalitis.

• Metabolic disturbances: Hypoglycemia, hyperglycemia, electrolyte imbalance (hyponatremia, hypercalcemia), dehydration, liver or kidney failure.

• Medications: Anticholinergics, opioids, sedatives, corticosteroids, benzodiazepines, or polypharmacy.

• Neurological conditions: Stroke, traumatic brain injury, seizures, brain tumors.

• Substance-related: Alcohol withdrawal (delirium tremens), intoxication from drugs or toxins.

• Cardiopulmonary causes: Hypoxia, hypercapnia, myocardial infarction, arrhythmias.

• Post-surgical states: Postoperative delirium, particularly after orthopedic or cardiac surgery.

• Environmental factors: Sleep deprivation, sensory deprivation, or overstimulation (especially in intensive care units).

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Symptoms of Delirium

The clinical presentation of delirium varies but generally involves:

• Cognitive disturbances: Sudden confusion, poor memory, disorientation to time/place, language difficulties.

• Attention deficits: Difficulty focusing, distractibility, inability to sustain a conversation.

• Fluctuating course: Symptoms may improve and worsen throughout the day (often worse at night).

• Perceptual disturbances: Hallucinations (visual > auditory), illusions, paranoia.

• Psychomotor changes: Hyperactive (agitation, restlessness), hypoactive (lethargy, drowsiness), or mixed.

• Emotional changes: Anxiety, irritability, depression, or inappropriate mood fluctuations.

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Diagnosis

Delirium is diagnosed clinically, based on history, mental status examination, and physical examination. Commonly used diagnostic tools include:

• Confusion Assessment Method (CAM) – widely used bedside tool.

• DSM-5 criteria for delirium – requiring acute onset, fluctuating course, attention and awareness disturbance, and an additional cognitive impairment.

• Laboratory and imaging investigations may include:

  • Full blood count, electrolytes, liver and kidney function tests.

  • Blood glucose levels.

  • Urine analysis and cultures.

  • Chest X-ray or brain CT/MRI if infection or neurological cause is suspected.

  • ECG and oxygen saturation monitoring.

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Treatment of Delirium

Management of delirium requires identifying and treating the underlying cause while providing supportive care to reduce symptoms and prevent complications.

1. General Principles

• Correct underlying medical problem (e.g., antibiotics for infection, fluids for dehydration, insulin for hyperglycemia).

• Ensure safety (prevent falls, remove hazardous objects).

• Provide orientation cues (clocks, calendars, familiar objects).

• Optimize sensory input (glasses, hearing aids).

• Maintain hydration, nutrition, and sleep-wake cycle.

• Minimize unnecessary medications and avoid polypharmacy.

2. Pharmacological Management

Pharmacological treatment is reserved for cases where patients are severely agitated, distressed, or pose a risk to themselves or others.

• Antipsychotics (preferred for severe agitation and hallucinations):

  • Haloperidol: 0.5–1 mg orally/IM/IV every 8–12 hours; titrate cautiously (maximum daily dose 5–10 mg).

  • Risperidone: 0.5–1 mg orally twice daily, may be increased to 2 mg/day.

  • Olanzapine: 2.5–5 mg orally once daily, can be increased if necessary.

  • Quetiapine: 12.5–25 mg orally twice daily, useful in patients with Parkinson’s disease or Lewy body dementia where haloperidol is contraindicated.

• Benzodiazepines (only for alcohol withdrawal delirium or benzodiazepine withdrawal):

  • Lorazepam: 0.5–1 mg orally/IM/IV every 4–6 hours as needed.

  • Diazepam: 5–10 mg orally/IV every 6–8 hours as needed.

• Other agents (rarely used):

  • Dexmedetomidine in ICU settings for sedation without respiratory depression.

3. Non-Pharmacological Interventions

• Encourage early mobilization and physiotherapy.

• Provide a calm, well-lit environment with reduced noise.

• Reassure and involve family members in care.

• Cognitive stimulation and frequent reorientation.

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Prognosis

• Delirium usually resolves once the underlying cause is treated, but recovery may take days to weeks.

• Some patients, especially older adults or those with dementia, may experience long-term cognitive impairment.

• Persistent or recurrent delirium is associated with increased mortality.

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When to Seek Medical Help

Immediate medical attention is required if someone develops sudden confusion, especially if accompanied by:

• Fever or signs of infection.

• Difficulty breathing, chest pain, or low oxygen levels.

• Seizures.

• Recent head injury.

• Inability to wake the patient or extreme drowsiness.

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Summary of Key Treatments with Generic Names and Doses

• Haloperidol: 0.5–1 mg PO/IM/IV every 8–12h (max 5–10 mg/day).

• Risperidone: 0.5–1 mg PO twice daily (up to 2 mg/day).

• Olanzapine: 2.5–5 mg PO daily.

• Quetiapine: 12.5–25 mg PO twice daily.

• Lorazepam: 0.5–1 mg PO/IM/IV every 4–6h (for alcohol withdrawal delirium).

• Diazepam: 5–10 mg PO/IV every 6–8h (for withdrawal-related delirium).