Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Delirium and Metabolic Encephalopathy

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In one line

·The brain suddenly stops thinking clearly and the confusion comes and goes within hours, almost always because something fixable—medicine, infection, dehydration, or broken chemistry—is attacking the brain right now.

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Normal physiology

·Your brain needs a steady supply of oxygen, sugar, balanced salts, and the right chemical signals to keep you awake, focused, and thinking clearly all day.

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What goes wrong

·Something suddenly hits the brain's fuel or chemistry—bad medicines, infection anywhere in the body, dehydration, low oxygen, unbalanced salts, or even just no sleep and a strange room—and the brain misfires, causing sudden confusion that comes and goes within hours.

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Hallmark signs

·Sudden confusion that comes and goes during the day
·Trouble paying attention or staying focused
·Disorganized, jumbled thinking or speech
·Either very restless and agitated (hyperactive) or very sleepy and slow to respond (hypoactive)
·Seeing or hearing things that are not there (hallucinations)
·Not knowing where they are, what time it is, or who people are (disorientation)
·Reversed sleep-wake cycle—awake and confused at night, drowsy during the day
·Sudden severe agitation, combativeness, or trying to pull out tubes and lines

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Red flags · escalate now

·Sudden drop in consciousness—person barely wakes or does not respond at all
·New seizure or repetitive jerking movements
·Fever with stiff neck or severe headache (signs of meningitis or encephalitis)
·Very high or very low blood sugar (under 54 mg/dL or over 400 mg/dL)
·New weakness on one side of the body, slurred speech, or drooping face (possible stroke)

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Workup

·Basic metabolic panel (BMP): sodium, potassium, chloride, bicarbonate (CO₂), blood urea nitrogen (BUN), creatinine, glucose
·Complete blood count (CBC) with differential
·Urinalysis with reflex to urine culture
·Arterial blood gas (ABG) or venous blood gas (VBG)
·Chest X-ray (posteroanterior and lateral views)
·Blood alcohol level and urine drug screen (if drug use, overdose, or withdrawal is suspected)
·Thyroid-stimulating hormone (TSH) and free T4 (if confusion is subacute or other causes have been ruled out)
·Electroencephalogram (EEG) — order only if confusion persists despite fixing obvious causes, or if you suspect non-convulsive status epilepticus (a seizure that will not stop) (the person is seizing continuously inside the brain without visible shaking)

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Treatment

·Identify and fix the root cause: give antibiotics (after drawing blood and urine cultures) for infection; infuse IV fluids with sodium or potassium to correct electrolyte imbalances; bring blood sugar into the 70–180 mg/dL range with insulin (if high) or glucose tablets or IV dextrose (if low); give supplemental oxygen by nasal cannula or mask to keep saturation above 92%; stop or reduce the offending medicine.
·Reorient the person constantly and gently: introduce yourself every time you enter the room; tell them where they are, what day it is, and why they are in the hospital; keep a large clock and calendar on the wall in clear view; let family members stay at the bedside as much as possible; open the curtains during the day so they see sunlight; turn off the lights and close curtains at night; reduce loud alarms, beeping monitors, and overhead pages.
·Keep the person hydrated (encourage sips of water every hour or give IV normal saline if they cannot drink), fed (offer small bites of food even if they only eat a little), moving (help them sit up in a chair and walk in the hallway three times a day if safe), and able to sense the world (give them their eyeglasses, hearing aids, and dentures if they use them).
·Stop or reduce anticholinergic medicines (diphenhydramine, hydroxyzine, oxybutynin, tolterodine, first-generation antihistamines), benzodiazepines (lorazepam, diazepam, alprazolam — unless treating alcohol or sedative withdrawal), and opioids (or switch to the smallest dose that controls pain, and choose opioids with fewer active brain metabolites like oxycodone or hydromorphone instead of morphine or meperidine).
·Use a low dose of an antipsychotic — haloperidol 0.5 to 1 mg by mouth, IV, or IM, or olanzapine 2.5 to 5 mg by mouth, or quetiapine 12.5 to 25 mg by mouth — ONLY if the person is in immediate danger to themselves or others (hitting staff, climbing out of bed and risking a fall, pulling out IV lines, breathing tubes, or catheters) AND only after you have tried every non-drug calming strategy first (reorientation, family presence, reducing noise and light).
·Do NOT use physical restraints (soft wrist or ankle ties, vests, bed rails used as barriers). Do NOT give benzodiazepines like lorazepam or midazolam to calm general delirium (they worsen it) — use them ONLY if the person is withdrawing from alcohol or sedative-hypnotics, where they prevent life-threatening seizures and autonomic storm. Do NOT sedate a quietly confused (hypoactive) person just because they seem 'out of it' — that hides deterioration and raises aspiration and pressure-ulcer risk.
·If the person is actively dying (end-stage cancer, heart failure, multi-organ failure) and comfort is the goal of care, focus on keeping them calm and pain-free with low-dose opioids (morphine 2–5 mg IV or subcutaneous every 4 hours, titrated to comfort) and stop blood draws, imaging, and treatments that cause distress without changing the outcome.

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NCLEX trap

·Benzodiazepines fog the brain even more and make delirium worse because they slow down GABA (the brain's main calming signal), which blurs thinking and memory even further. The ONLY time to use them is if the delirium is caused by alcohol or benzodiazepine withdrawal. The right order is: first, find what is broken (infection, low oxygen, bad electrolyte, new medicine, or stopped medicine). Second, fix that problem. Third, use calm talk, a quiet room, family at the bedside, and familiar objects like glasses or a clock to help the person feel safe and grounded.
·Restraints make delirium worse because they terrify the person and make them fight harder, which raises the risk of injury, skin breakdown, and deeper confusion. Instead, stay close or assign a sitter, bring family to the bedside, remove unnecessary tubes and lines as soon as it is safe, and treat the root cause. When the underlying problem (infection, low sugar, bad electrolyte, harmful drug) is fixed, the confusion fades and the person stops pulling.
·Antipsychotics do NOT cure delirium—they are only a safety tool if the person is at immediate risk of hurting themselves or others and non-drug methods (calm environment, reorientation, family presence) have failed. The real cure is finding and fixing the broken system: stopping the harmful drug, correcting the blood sugar, balancing the electrolytes (especially sodium and calcium), treating the infection with antibiotics, or giving oxygen. Antipsychotics cannot fix any of those root causes and carry risks like sedation, falls, QT prolongation (a heart rhythm problem), and extrapyramidal symptoms (stiff muscles and tremor).
·Delirium starts suddenly (within hours to 1–2 days) and the confusion waxes and wanes—alert one hour, confused the next. The person's level of awareness swings up and down throughout the day. Dementia starts slowly (months to years), the confusion is steady and progressive (not fluctuating), and awareness stays at a stable baseline until late in the disease. Delirium is reversible if you find and treat the cause. Dementia is a long-term neurodegenerative disease (like Alzheimer disease or vascular dementia) that is not reversible, though symptoms can be managed.
·New confusion in an older adult is delirium until proven otherwise, and it can be hiding a life-threatening problem: heart attack (myocardial infarction) (heart attack), pneumonia, urinary tract infection, stroke, low blood sugar (hypoglycemia) (low blood sugar) or high blood sugar (hyperglycemia) (high blood sugar), sepsis, or a harmful medication (anticholinergics, opioids, benzodiazepines, or polypharmacy). Always check: complete blood count, comprehensive metabolic panel (electrolytes, glucose, kidney function, liver function), urinalysis and culture, vital signs, oxygen saturation, electrocardiogram, and a full medication reconciliation. Treat the cause and the confusion will lift.
·Delirium can be caused by sodium that is too low (hyponatremia, under 135 mEq/L) or too high (hypernatremia, over 145 mEq/L). Giving the wrong type or amount of fluid can push sodium in the wrong direction too fast and cause osmotic demyelination syndrome (brain cell damage from rapid sodium shift) if correcting low sodium (hyponatremia), or worsen brain cell shrinkage and seizures if worsening high sodium (hypernatremia). Always check a basic metabolic panel (sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose) first, then give the right fluid (normal saline, half-normal saline, or D5W) at the right speed based on what the numbers show. For low sodium, do not raise sodium faster than 6–8 mEq/L in 24 hours unless the person is seizing.

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