Clinical Features

Delirium, or acute confusional state, is acute in the sense that it is present over days to weeks; by definition less than 1 month, although rapid onset may be noted. Attention and the cognitive functions of perception, thinking, and memory are all distorted to varying degrees. Alertness (but not necessarily consciousness) is reduced. The patient may appear quite awake but attention is impaired. Activity levels may be increased with agitation or decreased in a quiet delirium. Three variants are described: a hypoalert-hypoactive type, a hyperalert-hyperactive type, and a mixed type. The patient with the mixed variety may fluctuate rapidly between hypoactive and hyperactive states. Symptoms may be intermittent, and it is not unusual for different caregivers to witness completely different behaviors within a brief time span.3 The sleep-wake cycles are often disrupted with increased somnolence during the day and agitation at night. The increased nocturnal agitation is commonly referred to as "sundowning." Tremor or asterixis may be present in some patients. Associated symptoms may be present, such as tachycardia, sweating, hypertension, or emotional outbursts.

Hallucination, delusions, and illusions may be present in up to 40 percent of cases of delirium. 1 Hallucinations tend to be visual, though auditory hallucinations may occur.

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