Can steroids cause delirium?

Steroids and Delirium: Causal Relationship and Clinical Implications

Yes, steroids can cause delirium, particularly at high doses, and should be used with caution in patients at risk for cognitive disturbances. 1, 2

Mechanism and Risk

Corticosteroids can induce psychiatric disturbances ranging from mild mood changes to severe delirium and psychosis. The FDA drug label for prednisone explicitly warns that:

• Psychiatric derangements may appear when corticosteroids are used, ranging from euphoria, insomnia, and mood swings to severe depression and frank psychotic manifestations 2
• Existing emotional instability or psychotic tendencies may be aggravated by corticosteroids 2

Risk Factors for Steroid-Induced Delirium

• Dose-related risk: High-dose steroids (e.g., hydrocortisone >300 mg/day or prednisolone >75 mg/day) significantly increase delirium risk 1
• Age: Older adults are particularly vulnerable
• Pre-existing cognitive impairment
• Concurrent medications: Especially when combined with other medications that can cause delirium (opioids, benzodiazepines) 1
• Medical comorbidities: Especially liver or kidney dysfunction

Clinical Presentation

Steroid-induced delirium typically presents with:

• Fluctuating level of consciousness
• Inattention and disorganized thinking
• Perceptual disturbances (hallucinations, illusions)
• Mood lability and personality changes
• Onset usually within days of starting high-dose steroid therapy

Prevention and Management

Prevention Strategies

1. Use lowest effective dose: Minimize steroid dose and duration whenever possible
2. Avoid high-dose regimens when alternatives exist (>300 mg/day hydrocortisone or >75 mg/day prednisolone) 1
3. Monitor closely: Particularly during the first few days of therapy and when increasing doses
4. Screen for risk factors: Identify patients with pre-existing cognitive impairment or psychiatric disorders

Management of Steroid-Induced Delirium

1. Reduce or discontinue steroids if clinically feasible
2. Antipsychotic medications may be necessary for symptom control:
   • Haloperidol 0.5-1 mg PO/SC starting dose (lower in elderly/frail patients) 1
   • Alternative options include olanzapine (2.5-5 mg) or quetiapine (25 mg) 1, 3
3. Avoid benzodiazepines as they may worsen delirium (exception: alcohol withdrawal) 1
4. Non-pharmacological interventions:
   • Reorientation strategies
   • Maintaining day-night cycle
   • Familiar surroundings when possible

Special Considerations

• Inhaled corticosteroids: While systemic effects are reduced, high-dose inhaled steroids can still cause delirium, particularly in elderly patients 4
• Anabolic steroids: Can also induce delirium and psychiatric symptoms, as documented in case reports 3
• Withdrawal: Abrupt discontinuation of steroids can precipitate delirium; tapering is recommended when feasible 2
• Recurrent episodes: Some patients may experience sensitization with repeated steroid courses 5

Clinical Pitfalls to Avoid

• Misattribution: Steroid-induced delirium may be misattributed to other causes, especially in complex medical patients
• Delayed recognition: Symptoms may develop gradually and be overlooked
• Inadequate monitoring: Failure to monitor mental status changes in patients on high-dose steroids
• Polypharmacy: Adding other medications that can contribute to delirium risk

Steroids remain an essential therapeutic tool in many conditions, but clinicians should maintain awareness of their potential to cause delirium, particularly at higher doses and in vulnerable populations.