Can steroids cause delirium?

Steroids Can Cause Delirium

Yes, steroids can cause delirium, and they are specifically identified as delirium-inducing medications that should be reduced or eliminated when possible in patients at risk. 1

Mechanism and Evidence

• Corticosteroids are directly listed as risk factors for delirium in multiple clinical practice guidelines, particularly in cancer patients and critically ill populations 1
• The FDA drug label for prednisone explicitly lists delirium as a neuropsychiatric adverse reaction 2
• Steroids can cause neuropsychiatric effects through several proposed mechanisms:
  • Modification of the hypothalamic-pituitary-adrenal axis
  • Disruption of natural sleep-wake cycles
  • Hyperarousal caused by modification in neuroinhibitory pathways 3

Risk Factors and Vulnerable Populations

• High-dose steroids significantly increase the risk of delirium 1
• Even low doses (5-15mg of prednisone) can trigger delirium in vulnerable elderly patients 4
• Patients with multiple vulnerabilities are at higher risk:
  • Advanced age
  • Pre-existing cognitive impairment
  • Cancer patients, particularly those with:
    • Haematological malignancies
    • Bone metastases
    • Hypoalbuminaemia 1

Clinical Presentation

Steroid-induced delirium may present as:

• Hypoactive delirium (reduced psychomotor activity, lethargy, decreased speech)
• Hyperactive delirium (agitation, restlessness, increased speech)
• Mixed delirium (fluctuating features of both) 1
• Symptoms can include:
  • Cognitive disturbances (impaired attention, disorientation)
  • Perceptual disturbances (hallucinations, delusions)
  • Sleep-wake cycle disturbances 1

Management Approach

1. Prevention:

   • Avoid high-dose steroids when possible 1
   • Use the smallest possible effective dosage and duration 2
   • Be particularly cautious when prescribing steroids to vulnerable elderly patients 4

2. If delirium occurs:

   • Reduce or eliminate steroids if clinically feasible 1
   • Implement non-pharmacologic interventions first (reorientation, cognitive stimulation, sleep hygiene) 1
   • For moderate delirium: Consider oral haloperidol, risperidone, olanzapine, or quetiapine 1
   • For severe delirium with agitation: Consider antipsychotic medications such as haloperidol, olanzapine, or chlorpromazine 1
   • For refractory agitation: A benzodiazepine like lorazepam may be added to neuroleptics 1

Important Considerations

• Steroid-induced delirium can occur with both short-term and long-term use 5
• There appears to be a dose-dependent relationship, with higher doses carrying greater risk 5
• Some patients may experience sensitization with multiple courses of steroids, leading to recurrent episodes 5
• Even anabolic steroids (used for bodybuilding) can trigger delirium 6
• Untreated steroid-induced delirium can lead to:
  • Prolonged hospitalization
  • Weight loss and malnutrition
  • Increased care needs 4

Clinical Pitfalls to Avoid

• Don't overlook hypoactive delirium, which is often underdiagnosed but is the most prevalent subtype in palliative care patients 1
• Don't use benzodiazepines as initial treatment for steroid-induced delirium unless the patient is already taking them 1
• Don't forget that multiple medications can contribute to delirium simultaneously (particularly opioids, benzodiazepines, and corticosteroids) 1
• Remember that even low doses of steroids can cause delirium in vulnerable patients 4