Delirium: what is it, causes, symptoms, treatment, prognosis

General information about the disease

Delirium Is a sudden, unstable and usually reversible impairment of mental function. This disorder is characterized by inability to focus, disorientation, inability to think clearly and fluctuations in the level of perception (consciousness).

Delirium is a pathological mental disorder, not a disease. Although the term has a specific medical definition, it is often used to describe any type of confusion.

Delirium is never a normal condition and often indicates a usually serious, recent pathology, especially in the elderly. People with the disorder need urgent medical attention. When the cause of delirium is identified and quickly corrected, the disorder can usually be cured.

Because delirium is a temporary disorder, it is difficult to determine the extent of the disorder in a population. Delirium affects 15-50% of hospitalized patients aged 70 and over.

Delirium can occur at any age, but is most common in older people. Delirium is common in nursing homes. If the disorder occurs in younger people, the cause is usually drug use or a life-threatening illness.

Causes and risk factors

The development or aggravation of many diseases can cause delirium. Anyone can get delirium if they are seriously ill or if they take drugs that affect brain function (psychotropic drugs).

Generally the most common Delirium is caused by:

• Medicines, in particular anti-cholinergic medicines, psychoactive medicines and opioids;
• Dehydration of the body;
• Infections, for example pneumonia, bloodstream infection (sepsis), infections affecting the whole body or causing an increase in body temperature, and urinary tract infections;
• Renal failure, liver failure and low oxygen levels in the blood (hypoxia, which can occur with pneumonia), especially if these disorders occur suddenly and progress rapidly.

Other reasons include hospitalization, surgery, drug withdrawal, certain disorders, and poisoning.

Delirium may result from less severe illness in older people and may also occur in patients with stroke or dementia, Parkinson's disease or another disorder that causes nerve degeneration. These factors include:

• mild illness (eg, urinary tract infection;
• heavy constipation;
• pain;
• Using a bladder catheter (a thin tube to drain urine from your bladder)
• dehydration;
• prolonged sleep deprivation;
• sensory deprivation (including social isolation and lack of required glasses or hearing devices).

In some patients, it is not possible to establish the cause.

- Hospitalization.

A hospital stay, especially in an intensive care unit (ICU), can contribute to or initiate delirium.

In the ICU, patients are isolated in a ward that usually does not have windows or clocks. Thus, patients are deprived of normal sensory stimulation and may become disoriented. Sleep is interrupted by staff who wake patients up at night for observation and treatment, as well as loud signals from monitors, intercom calls, voices in the hallway, or alarms. Moreover, patients are admitted to the ICU with serious illnesses and are treated with drugs that increase the likelihood of delirium.

Patients in the ICU may experience epileptic seizuresthat do not cause seizures (called non-convulsive seizures). These seizures can cause delirium, but these seizures may not be recognized because they do not present with seizures or other typical epileptic seizure symptoms. If seizures are not recognized, patients may not receive proper emergency treatment.

- Surgical intervention.

Delirium is also very common after surgery, possibly due to operational stress, using anesthetics during surgery, as well as pain relievers (analgesics) used after operations.

Delirium can also develop in people shortly before surgery if they do not have access to previously used substances, such as drugs, alcohol or tobacco. When people stop using these substances, they may develop withdrawal symptoms, including delirium.

- The use of drugs.

The most common reversible cause of delirium is drugs. In younger people, use of illegal drugs and acute alcohol intoxication are common causes. In older people, prescription drugs are usually the cause.

Psychotropic drugs directly affect nerve cells in the brain, sometimes causing delirium. These include:

• Opioids (including morphine and meperidine);
• Sedatives (including benzodiazepines and sleeping pills)
• Antipsychotics;
• Antidepressants.

Many other drugs can also cause delirium. Here are some examples:

• Anticholinergic drugs, including many over-the-counter antihistamines;
• Amphetamines and cocaine, which are stimulants;
• Cimetidine;
• Corticosteroids;
• Digoxin and some other drugs used to treat heart disease;
• Levodopa;
• Muscle relaxants.

- Cancellation of the drug.

Delirium may also result from sudden discontinuation of a drug that has been used for an extended period of time. time, such as sedation (such as a benzodiazepine or barbiturate) or opioid pain reliever funds.

Delirium is common in alcoholics who suddenly stop drinking (called alcoholic delirium) and heroin addicts who suddenly stop using it.

- Disorders.

Abnormal levels of electrolytes in the blood, such as calcium, sodium, or magnesium, can interfere with the metabolic activity of nerve cells and lead to delirium. Electrolyte imbalances can result from diuretic use, dehydration, or medical conditions such as kidney failure and advanced cancer.

Blood glucose - extremely high (hyperglycemia) or extremely low (hypoglycemia) - is often the cause of delirium.

Insufficient thyroid activity (hypothyroidism) causes delirium, accompanied by lethargy. Overactive thyroid (hyperthyroidism) causes delirium, accompanied by hyperactivity.

If an undiagnosed develops liver failure or renal failureA drug taken for a long time can cause delirium even if it has not previously caused any complications. In these conditions, the liver or kidneys do not process or excrete the drug as it should. As a result, the drug can build up in the blood and enter the brain, causing delirium.

Have young people (after excluding drug and alcohol use) delirium is usually caused by:

• a condition that directly affects the brain - for example, a brain infection such as meningitis or encephalitis.

Have old people the reason is often:

• a common infection, such as a urinary tract infection, pneumonia, or flu.

Such infections can indirectly affect the brain.

Wernicke's encephalopathyresulting from a severe deficiency vitamin b - thiamine, can cause confusion and delirium. Left untreated, Wernicke's encephalopathy can cause severe brain damage, coma, or death.

In younger people, the use of poisons, such as rubbing alcohol or antifreeze, is a common cause of delirium.

Signs and symptoms

Delirium usually begins suddenly and progresses over hours or days. In delirium, the actions of patients can be different, but they are roughly similar to the actions of a person who becomes more and more drunk.

The hallmark of delirium - inability to focus.

Patients with delirium cannot concentrate, so they have trouble processing new information and cannot remember recent events. Thus, they do not understand what is happening around them. Patients become disoriented. Sudden disorientation in time, as well as often in space (where they are), can be an early sign of delirium. If the disorder is severe, the patient may not know who he is and who the other people around him are. Thinking is clouded, patients with delirium jump from one topic to another in conversation, and sometimes their speech becomes incoherent.

Their level of perception (consciousness) may be unstable. Those. at some point, the patient may be overly agitated, and soon after, sleepy and lethargic. Other symptoms also often change within a few minutes and usually get worse in the evening (a phenomenon called nocturnal confusion).

Patients with delirium often sleep restlessly or confuse the sleep-wake cycle, that is, they sleep during the day and are awake at night.

Patients may have bizarre, frightening visual hallucinations - seeing objects or people that don't really exist. Some patients develop paranoia or delusions (false beliefs, usually based on a misinterpretation of perception or experience).

Personality and mood can change. Some patients become so quiet and detached that no one notices the development of their disorder. Others become irritable, agitated, and restless, and may walk from corner to corner. Patients who develop delirium after taking sedatives tend to become very sleepy and withdrawn. Patients who are taking amphetamines or withdrawing sedatives may become aggressive and hyperactive. Some patients alternate between these two types of behavior.

The condition can last for hours, days, or even longer, depending on the severity and cause. If the cause of delirium is not quickly identified and treated, patients become increasingly sleepy and no matter what unresponsive, which requires intense stimulation to remain active (a condition called stupor). Stupor can lead to coma or death.

Diagnostics

Doctors may suspect delirium on the basis of symptoms, especially if the patient is unable to concentrate and also if his ability to concentrate is constantly changing. However, mild delirium can be difficult to recognize. Doctors may not recognize the disorder in hospitalized patients.

Most patients with suspected delirium are hospitalized for evaluation and protection from injury to themselves or others. In the hospital, diagnostic procedures are performed quickly and safely, and any abnormalities identified can be treated immediately.

Because the disorder can be caused by a serious illness (which can quickly become fatal), doctors try to identify the cause as soon as possible. Once the cause is identified, treating it can often correct the problem.

Above all, doctors try to distinguish delirium from other disorders that impair mental function. To do this, doctors collect as much information as possible about the patient's medical history, conduct a physical examination and tests.

- Medical history.

Friends, family members or other observers are asked to provide information, as patients with delirium are usually unable to answer questions. Questions include the following:

• How disorientation began (suddenly or gradually);
• How quickly she progressed;
• What was the patient's physical and mental health;
• What medications (including alcohol and drugs, especially if the patient is young) and food additives (including medicinal herbs) the patient uses;
• Have not started or recently stopped taking any medications.

Information can also be obtained from medical records, from emergency medical personnel help, or based on evidence, such as empty pill vials and certain documents. Documents such as a checkbook, recent letters, or notices of unpaid bills or missed appointments can indicate changes in mental function.

If delirium is accompanied by agitation and hallucinations, delusions or paranoia, the disorder must be distinguished from psychosis due to mental illness, for example manic-depressive psychosis or schizophrenia. Patients with psychosis due to mental illness do not develop disorientation or memory loss, nor do they change their level of perception. Psychosis that begins in old age is usually a sign of delirium or dementia.

- Physical examination.

During a physical exam, doctors check for signs of delirium-causing illness, such as infections and dehydration. A neurological examination is also performed.

Patients with suspected delirium are assessed for mental status. Questions are first asked to determine if the primary impairment is inability to concentrate. For example, a short list is read to the patient and asked to repeat it. The physician must determine whether the patient is perceiving (capturing) what is being read to him. Patients with impairment cannot do this. The mental status assessment also includes other questions and tasks, such as testing short-term and long-term memory, naming objects, writing sentences, and sketching the shape of objects.

- Carrying out analyzes.

Blood and urine samples are usually taken and analyzed to identify the underlying conditions for delirium. For example, an imbalance in electrolytes and blood glucose levels, liver disease and kidney problems often cause delirium. Therefore, doctors usually do blood tests to measure electrolyte and blood glucose levels, to evaluate liver and kidney function.

If the doctor suspects thyroid diseasetests may be done to assess thyroid function. Or, if a doctor suspects that certain drugs may be the cause, tests are done to determine the level of drugs in the blood. Such tests can help determine if the drug level is high enough to cause harmful effects, and if the patient has taken too high a dose.

Bacterial culture is performed to detect infection.

Computed tomography (CT) or magnetic resonance imaging (MRI) of the brain is done.

Sometimes, a test that records the electrical activity of the brain (electroencephalography, or EEG).

Electrocardiography (ECG), pulse oximetry (using a sensor that measures oxygen in the blood), and chest x-ray are used to assess heart and lung function.

For people with a fever or headache, a lumbar puncture (lumbar puncture) may be done to obtain a sample of cerebrospinal fluid for analysis. This test helps doctors rule out infection or bleeding in the brain and spinal cord.

Treatment

Most patients with delirium are hospitalized. However, if the cause of delirium can be easily corrected (for example, if blood glucose is low), patients are usually seen briefly in the emergency department and then are discharged.

- Treatment of the cause.

Once the cause is established, immediate correction or treatment is carried out. For example, doctors treat infections with antibiotics, dehydration with fluids and electrolyte solutions through intravenous administration, and delirium due to the cessation of alcohol use - benzodiazepine drugs (as well as measures to help patients not to resume use alcohol).

Immediate treatment of the underlying delirium usually prevents permanent brain damage and can lead to full recovery.

Any medication that aggravates the condition is stopped if possible.

- General recommendations.

It is also important to apply general measures.

The surrounding area should be as quiet and calm as possible. The space should be well lit so that the patient can recognize objects and people in the room, know where he is. Placement of clocks, calendars and family photos in the room helps with orientation. Whenever possible, staff and family members should reassure the patient and remind him of the present time and place. The procedures should be explained before and during the procedure. Patients using glasses or hearing aids should have them close at hand.

Patients with delirium are prone to many disorders, including dehydration, malnutrition, incontinence, falls, and bedsores. Careful care is required to prevent such problems. Thus, patients, especially the elderly, may benefit from multidisciplinary treatment. group, which includes a physician, physical therapist and occupational therapist, nurses and social workers.

- Reducing arousal.

Patients who are extremely agitated or experiencing hallucinations can injure themselves or their caregivers. Such injuries can be prevented by taking the following measures:

• It is recommended that a family member be near the patient.
• Place the patient in the ward next to the nursing staff.
• The hospital can provide an attendant to be close to the patient.
• If possible, avoid using devices such as droppers, bladder catheters, or soft restraining devices, since the patient's disorientation and frustration can be amplified at the same time, increasing risk of injury.

However, sometimes during a hospital stay, soft restraints are indispensable, for example, to keep the patient from pulling out an installed dropper or to prevent falls. Restriction devices are carefully installed by personnel trained in the use of such devices, and the devices are often are removed, and their use is discontinued as soon as possible, since they can upset the patient and aggravate agitated condition.

Medications to reduce arousal, they are used only after all other measures have been tried and they have been ineffective. Two types of drugs are commonly used to control arousal, but neither is ideal:

• Antipsychotics are used most often. However, antipsychotics can prolong and aggravate the state of arousal, and some also have anticholinergic effects, causing disorientation, blurred vision, constipation, dry mouth, dizziness, difficulty starting and continuing urination, loss of control over the function of the bladder. More recent antipsychotics such as risperidone, olanzapine and quetiapine have fewer side effects than older antipsychotics such as haloperidol. But when used for a long time in people with dementia, more advanced drugs may increase the risk. stroke or death.
• Benzodiazepines (a type of sedative - drugs used to treat anxiety disorders), such as lorazepam, are used if delirium occurs due to discontinuation of a sedative or use of alcohol. Benzodiazepines are not used to treat delirium due to other disorders because they lead to increased disorientation, drowsiness, or both, especially in the elderly.

Doctors prescribe these drugs with caution, especially in older people. The drugs are prescribed in the minimum dosage, and their intake is discontinued as soon as possible.

Forecast

Most patients recover completely if the disorder causing delirium is identified and treated promptly. Any delay in treatment reduces the likelihood of complete recovery. Even after delirium is treated, some symptoms may persist for weeks or months, and improvement may be slow. In some patients, the disorder develops into chronic brain dysfunction similar to dementia.

Hospitalized patients with delirium are more likely to develop complications (including death) in the hospital than patients without delirium. Approximately 35–40% of patients who develop delirium in hospital die within 1 year, but the cause of death is often a serious illness other than delirium.

Hospitalized patients with diagnosed delirium, especially the elderly, stay in the hospital longer, and the recovery period after discharge from the hospital is also longer.

Prophylaxis

To prevent delirium in older adults, family members can ask hospital staff for help while in hospital by doing the following:

• Ask the patient to walk around the room regularly.
• Bring the clock and calendar to the ward.
• Minimize sleep interruptions and noise during the night.
• Ensure that the patient eats and drinks in sufficient quantities.

Family members can visit and talk to the patient to maintain current awareness. Delirious patients may be fearful, and the familiar voice of a loved one has a calming effect.