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This week on the podcast, I am joined by Dr. Timothy Lee, the Loma Linda residency program director and the head of medical consult and liaison services. One of his specialities is delirium, so this week we will be discussing both hypoactive and hyperactive delirium.  What is delirium? Delirium is an acute change in a person’s sensorium (the perception of one’s environment or understanding of one’s situation). It can include confusion about their orientation, cognition or mental thinking.With hyperactive delirium, a patient can become aggressive, violent and agitated with those around them. A patient experiencing delirium can have hallucinations and hear things, they can become paranoid, and they are overall confused. A family, or non-psychiatric medical staff, might be concerned that the patient is experiencing something like schizophrenia. Hyperactive delirium symptoms in patients:Waxing and waning—it comes and goesIssues with concentrationPulling out medical linesYelling profanitiesThrowing thingsAgitatedResponding to things in the room that aren’t thereNot acting like themselvesHypoactive delirium is much more common than hyperactive delirium (based on research studies), but it is often missed because the presentation is much less dramatic. People with hypoactive delirium are confused and disoriented, but they do not express their confusion verbally or physically.Hypoactive delirium symptoms:Slower movementSofter speechSlower responsesWithdrawnNot eating as muchOften, nurses and physicians can miss the fact that the patient has the typical confusion that denotes delirium because the patient is quieter, so it doesn’t come to the attention of the medical team or psychiatrist consult service. Delirium can even be confused for depression. One Mayo Clinic study showed that when consulting a doctor about their depression, 67% of the time, the patient ended up having delirium. Why does delirium happen? Often we see it happen, even to relatively healthy people, in physically stressful situations—post surgery, during an acute illness, or even just being stuck in the hospital for a few days. This does not mean it is indicative of a sudden onset of a long term mental illness, such as schizophrenia.To consider what can cause delirium, I like to think systematically from the top of the body and work my way down. This is by no means exhaustive, but it can be helpful. Many things can cause delirium. I like to think about starting at the top of the body and going down, as a way to not miss the cause. Here are a few we would consider as we go down the body:Stroke—check strength in both arms and legs, have the patient smileHypertensive emergencyInfection or meningitisPhysical trauma—concussion, head injury with initial loss of consciousness, then after regaining consciousness they can have deliriumBrain bleedingMedications that affect the brain, such as ones that produce anticholinergic side effects. (They suppress acetylcholine, causing brain imbalances and confusion. Anti-allergy medicines, pain medications, and some psychiatric medications are anticholinergic.) Circulatory issuesThyroid imbalances or parathyroid hormonesCancer Heart attackTraumatic injury to the heartAspiration pneumonia Lung infectionLung cancerViral pneumoniaPancreatic inflammationUrinary tract infections in womenLiver cirrhosisHepatitisGallbladder inflammationLow bilirubinHepatic encephalopathy How do we identify delirium in a patient? Asking certain questions to the patient and/or medical team and family can help us understand if the patient is experiencing delirium. Often, a patient experiencing delirium will still know where they are, what they are doing, and who they are. The main test to really determine if it’s delirium is the “clock drawing” where we ask the patient to draw a clock with the hands showing 11:10.Here are some questions and tasks we ask th