Can steroids cause delirium?

Steroids Can Cause Delirium

Yes, steroids can cause delirium, particularly in vulnerable populations such as the elderly, and this is a well-documented adverse effect that requires careful monitoring and management. 1, 2

Mechanism and Risk Factors

Steroids can induce delirium through several pathways:

• Modification of the hypothalamic-pituitary-adrenal axis, leading to behavioral changes 3
• Disruption of natural sleep-wake cycles 3
• Hyperarousal caused by alterations in neuroinhibitory pathways 3
• Neuropsychiatric effects that can manifest as cognitive disturbances 1

Risk factors that increase vulnerability to steroid-induced delirium include:

• Advanced age 2
• Pre-existing cognitive impairment 2
• Higher doses of steroids 2, 4
• Longer duration of steroid therapy 3
• Multiple comorbidities 5

Clinical Presentation

Steroid-induced delirium can present in various forms:

• Hypoactive delirium: reduced psychomotor activity, lethargy, decreased speech 2
• Hyperactive delirium: increased psychomotor activity, agitation, restlessness 2
• Mixed delirium: fluctuating features of both hypoactive and hyperactive forms 2

Common symptoms include:

• Cognitive disturbances (impaired attention, disorientation, memory impairment) 2
• Perceptual disturbances (hallucinations, illusions) 2
• Sleep-wake cycle disturbances 2
• Emotional lability, euphoria, or depression 1
• Psychotic manifestations (delusions, personality changes) 1, 6

Evidence from Guidelines and Drug Labels

The FDA drug label for prednisone explicitly lists delirium as an adverse neuropsychiatric effect 1. The label states that psychiatric derangements ranging from euphoria and mood swings to severe depression and frank psychotic manifestations can occur with corticosteroid use 1.

Clinical practice guidelines identify corticosteroids as risk factors for delirium:

• The ESMO Clinical Practice Guidelines for delirium in adult cancer patients specifically list corticosteroids among medications implicated as risk factors for delirium 2
• The NCCN Palliative Care Guidelines identify steroids as delirium-inducing medications that should be reduced or eliminated when possible 2
• Guidelines for sepsis management explicitly warn that high-dose steroids increase the risk of delirium 2

Management Recommendations

When steroid-induced delirium occurs or in patients at high risk:

• Reduce or eliminate steroids when possible 2
• Use the lowest effective dose for the shortest duration necessary 3
• Consider alternative treatments if appropriate 2
• For patients requiring continued steroid therapy with delirium symptoms:
  • Antipsychotics may be needed for symptom management (haloperidol, risperidone, olanzapine, or quetiapine) 2
  • For severe agitation refractory to antipsychotics, a benzodiazepine such as lorazepam may be added 2

Prevention and Monitoring

To minimize the risk of steroid-induced delirium:

• Avoid high-dose steroids (e.g., hydrocortisone >300 mg/day or prednisolone >75 mg/day) unless specifically indicated 2
• Use particular caution when prescribing steroids to elderly or frail patients 5
• Monitor for early signs of delirium, especially within the first few days of starting steroid therapy 5
• Consider prophylactic use of mood stabilizers like lithium in patients with history of steroid-induced psychiatric symptoms 7

Case Evidence

Case reports demonstrate that even low doses of steroids can induce severe delirium in vulnerable patients:

• A 91-year-old man developed severe delirium with agitation, aggression, and visual hallucinations just 3 days after starting low-dose prednisone (5-15 mg), resulting in a prolonged 36-day hospitalization 5
• A 33-year-old man developed delirium with aggression, hostility, and destructive impulses associated with anabolic steroid use 6

These cases highlight that steroid-induced delirium can occur at various doses and across different age groups, though elderly patients appear particularly susceptible.