Can steroids cause delirium?

Steroids Can Cause Delirium

Yes, steroids can cause delirium, and this is a well-documented adverse effect that should be carefully monitored, especially in vulnerable populations such as the elderly or those with multiple comorbidities. 1, 2

Mechanism and Risk

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, contributing to cognitive impairment 3
• Hyperarousal caused by alterations in neuroinhibitory pathways 3

Risk Factors for Steroid-Induced Delirium

Patients at higher risk of developing steroid-induced delirium include:

• Elderly patients 4
• Those with pre-existing cognitive impairment 2
• Patients with multiple comorbidities (liver failure, renal failure, CNS diseases) 2
• Those on high-dose steroid therapy 2
• Patients with a history of psychiatric disorders 1

Clinical Presentation

Steroid-induced delirium can manifest in various ways:

• Cognitive disturbance (impaired attention, disorientation, memory deficits) 2
• Perceptual disturbances (hallucinations, illusions) 2
• Psychomotor changes (hypoactive, hyperactive, or mixed presentations) 2
• Sleep-wake cycle disturbances 2
• Mood changes (euphoria, depression, irritability) 1

The onset can be rapid, with symptoms appearing within days of starting steroid therapy, even at relatively low doses in vulnerable patients 4.

Evidence from Clinical Guidelines and Drug Labels

The FDA drug label for prednisone explicitly lists delirium among its neuropsychiatric adverse effects 1. The label states that steroids can cause "delirium, dementia (characterized by deficits in memory retention, attention, concentration, mental speed and efficiency, and occupational performance), depression, dizziness, emotional instability and irritability, euphoria, hallucinations" 1.

Clinical guidelines for sepsis management specifically warn against high-dose steroids due to increased risk of delirium, among other adverse effects 2. The ESMO Clinical Practice Guidelines for delirium in adult cancer patients identify corticosteroids as risk factors for delirium 2.

Management Approach

When steroid-induced delirium is suspected:

1. Consider dose reduction or discontinuation of the steroid if clinically feasible 2

2. Treat symptoms if necessary with antipsychotics:

   • For moderate delirium: oral haloperidol, risperidone, olanzapine, or quetiapine 2
   • For severe delirium with agitation: haloperidol, olanzapine, or chlorpromazine 2
   • Benzodiazepines should not be used as initial treatment for delirium unless treating alcohol or benzodiazepine withdrawal 2

3. Implement non-pharmacological interventions:

   • Reorientation strategies 2
   • Cognitive stimulation 2
   • Sleep hygiene measures 2

Prevention Strategies

To minimize the risk of steroid-induced delirium:

• Use the lowest effective dose and shortest duration of steroid therapy possible 2, 3
• Be particularly cautious when prescribing steroids to elderly or vulnerable patients 4
• Consider prophylactic use of mood stabilizers like lithium in high-risk patients or those with a history of steroid-induced psychiatric symptoms 5
• Monitor patients closely for early signs of delirium, especially during the first few days of steroid therapy 4

Important Clinical Considerations

• Even low doses of steroids (as little as 5-15 mg of prednisone) can trigger delirium in vulnerable elderly patients 4
• Steroid-induced delirium can lead to prolonged hospitalization, weight loss, and increased care needs 4
• The risk appears to be dose-dependent, with higher doses carrying greater risk 5
• A sensitization process may occur with multiple courses of steroids, potentially leading to recurrent episodes 5

Clinicians should maintain a high index of suspicion for delirium when prescribing steroids, particularly in high-risk populations, and should be prepared to adjust therapy promptly if neuropsychiatric symptoms develop.