Delirium (acute confusional state) is a common and severe neuropsychiatric syndrome with core features of acute onset and fluctuating course, attentional deficits and generalized severe disorganization of behavior. It typically involves other cognitive deficits, changes in arousal (hyperactive, hypoactive, or mixed), perceptual deficits, altered sleep-wake cycle, and psychotic features such as hallucinations and delusions. It is often caused by a disease process 'outside' the brain, such as common forms of infection (UTI, pneumonia) or by drug effects, particularly anticholinergic or other CNS depressants (benzodiazapenes and opioids). It can also be caused by virtually any primary disease of the central nervous system The central nervous system is the part of the nervous system that coordinates the activity of all parts of the bodies of bilaterian animals—that is, all multicellular animals except sponges and radially symmetric animals such as jellyfish. It contains the majority of the nervous system and consists of the brain and the spinal cord, as well as. Though hallucinations A hallucination, in the broadest sense of the word, is a perception in the absence of a stimulus. In a stricter sense, hallucinations are defined as perceptions in a conscious and awake state in the absence of external stimuli which have qualities of real perception, in that they are vivid, substantial, and located in external objective space. The and delusions A delusion is, a fixed belief that is either false, fanciful, or derived from deception. The psychiatric definition of delusion is similarly, a belief that is pathological and is held despite evidence to the contrary.} As a pathology, it is distinct from a belief based on false or incomplete information, dogma, stupidity, apperception, illusion, are sometimes present, these are not required for the diagnosis, and the symptoms of delirium are clinically distinct from those induced by psychosis Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality". People suffering from psychosis are described as psychotic or hallucinogens The general group of pharmacological agents commonly known as hallucinogens can be divided into three broad categories: psychedelics, dissociatives, and deliriants. These classes of psychoactive drugs have in common that they can cause subjective changes in perception, thought, emotion and consciousness. Unlike other psychoactive drugs, such as (with the exception of deliriants.) Although commonly referred to as a primary disorder of attention, other core cognitive processes are disrupted, particularly working memory and virtually all aspects of executive functions (planning and organization of behavior). Although it is commonly regarded as reversible, induction of delirium in patients with dementia due to Alzheimer's disease appears to accelerate cognitive decline, suggesting that efforts to prevent and minimize the induction of confusional states in the elderly should be given high priority. Unfortunately, many instances of confusional state (delirium) are iatrogenic (caused by medicines or hospital-borne pathogens/bacteria or surgeries and anesthesia).
In medical usage it is not synonymous with drowsiness, and may occur without it. Delirium is not the same as dementia Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging. It may be static, the result of a unique global brain injury, or progressive, resulting in long-term decline due to damage or disease in the body. Although dementia is far more common in the geriatric population, it (the two entities have different diagnostic criteria), though it commonly occurs in demented patients.
Delirium may be of a hyperactive variety manifested by 'positive' symptoms of agitation or combativeness, or it may be of a hypoactive variety (often referred to as 'quiet' delirium) manifested by 'negative' symptoms such as inability to converse or focus attention or follow commands. While the common non-medical view of a delirious patient is one who is hallucinating, most people who are medically delirious do not have either hallucinations or delusions. Delirium is commonly associated with a disturbance of consciousness (e.g., reduced clarity of awareness of the environment). The change in cognition (memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance, must be one that is not better accounted for by a pre-existing, established, or evolving dementia Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging. It may be static, the result of a unique global brain injury, or progressive, resulting in long-term decline due to damage or disease in the body. Although dementia is far more common in the geriatric population, it. Usually the rapidly fluctuating time course of delirium is used to help in the latter distinction.[1]
Delirium itself is not a disease, but rather a clinical syndrome In medicine and psychology, a syndrome is the association of several clinically recognizable features, signs , symptoms (reported by the patient), phenomena or characteristics that often occur together, so that the presence of one feature alerts the physician to the presence of the others. In recent decades, the term has been used outside medicine (a set of symptoms A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality. A symptom is subjective, observed by the patient, and not measured), which result from an underlying disease or new problem with mentation. Like its components (inability to focus attention Attention is the cognitive process of selectively concentrating on one aspect of the environment while ignoring other things. Attention has also been referred to as the allocation of processing resources, mental confusion Confusion of a pathological degree usually refers to loss of orientation , sometimes accompanied by disordered consciousness and often memory (ability to correctly recall previous events or learn new material). Confusion as such is not synonymous with inability to focus attention, although severe inability to focus attention can cause, or greatly and various impairments in awareness and temporal and spatial orientation), delirium is simply the common symptomatic manifestation of early brain or mental dysfunction (for any reason).
Without careful assessment, delirium can easily be confused with a number of psychiatric disorders A mental disorder or mental illness is a psychological or behavioral pattern that occurs in an individual and is thought to cause distress or disability that is not expected as part of normal development or culture. The recognition and understanding of mental disorders has changed over time and across cultures. Definitions, assessments, and because many of the signs and symptoms A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality. A symptom is subjective, observed by the patient, and not measured are conditions present in dementia Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging. It may be static, the result of a unique global brain injury, or progressive, resulting in long-term decline due to damage or disease in the body. Although dementia is far more common in the geriatric population, it, depression Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities. The term "major depressive disorder" was selected by the American Psychiatric Association to designate this symptom cluster as a mood disorder, and psychosis Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality". People suffering from psychosis are described as psychotic.[2] Delirium is probably the single most common acute disorder affecting adults in general hospitals. It affects 10-20% of all hospitalized adults, and 30-40% of elderly hospitalized patients and up to 80% of ICU An intensive care unit , critical care unit (CCU), intensive therapy unit or intensive treatment unit (ITU) is a specialized department used in many countries' hospitals that provides intensive care medicine. Many hospitals also have designated intensive care areas for certain specialities of medicine, as dictated by the needs and available patients.[3]
Treatment of delirium requires treatment of the underlying causes. In some cases, temporary or palliative or symptomatic treatments are used to comfort patients or to allow better patient management (for example, a patient who, without understanding, is trying to pull out a ventilation tube that is required for survival).
Educational information is available for medical and non-medical persons with videos, management protocols, links to references, lectures, recent evidence from studies, implementation packets for hospitals, and even comments to families and loved ones for those witnessing someone going through a delirious episode.[4] See the Resources section. Another useful source of information is the website of the European Delirium Association (EDA) www.europeandeliriumassociation.com. The EDA publish a regular newsletter highlighting current research and developments, which is also available from the site.
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Definition
In common usage, delirium is often used to refer to drowsiness, disorientation, and hallucination. In broader medical terminology Medical terminology is a vocabulary for accurately describing the human body and associated components, conditions, processes and process in a science-based manner. It is to be used in the medical and nursing fields. This systematic approach to word building and term comprehension is based on the concept of: Word roots, (2) prefixes, and (3), however, a number of other symptoms, including a sudden inability to focus attention, and even (occasionally) sleeplessness and severe agitation and irritability, also define "delirium," and hallucination, drowsiness, and disorientation are not required. Known before as 'acute confusional state', delirium is one of the oldest forms of mental disorder known in medical history.[5]
There are several medical definitions of delirium (including those in the DSM-IV The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders. It is used in the United States and in varying degrees around the world, by clinicians, researchers, psychiatric drug regulation agencies, and ICD-10 The International Statistical Classification of Diseases and Related Health Problems provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease. Under this system, every health condition can be assigned to a unique category and given a). However, all include some core features.
The core features are:
- Disturbance of consciousness (that is, reduced clarity of awareness of the environment, with reduced ability to focus, sustain, or shift attention)
- Change in cognition (e.g., problem-solving impairment or memory impairment) or a perceptual disturbance
- Onset of hours to days, and tendency to fluctuate.
Common features also tend to include:
- Intrusive abnormalities of awareness and affect Affect refers to the experience of feeling or emotion. Affect is a key part of the process of an organism's interaction with stimuli. The word also refers sometimes to affect display, which is "a facial, vocal, or gestural behavior that serves as an indicator of affect", such as hallucinations A hallucination, in the broadest sense of the word, is a perception in the absence of a stimulus. In a stricter sense, hallucinations are defined as perceptions in a conscious and awake state in the absence of external stimuli which have qualities of real perception, in that they are vivid, substantial, and located in external objective space. The or inappropriate emotional states.
Signs and symptoms
Since delirium may occur in very many grades of severity, all symptoms may occur with varying degrees of intensity. A mild disability to focus attention may result in only a disability in solving the most complex problems. As an extreme example, a mathematician with the flu may be unable to perform creative work, but otherwise may have no difficulty with basic activities of daily living. However, as delirium becomes more severe, it disrupts other mental functions, and may be so severe that it borders on unconsciousness or a vegetative state. In the latter state, a person may be awake and immediately aware and responsive to many stimuli, and capable of coordinated movements, but unable to perform any meaningful mental processing task at all.
Inability to focus attention, confusion and disorientation
The delirium-sufferer loses the capacity for clear and coherent thought. This may be apparent in disorganised or incoherent speech, the inability to concentrate (focus attention Attention is the cognitive process of selectively concentrating on one aspect of the environment while ignoring other things. Attention has also been referred to as the allocation of processing resources), or in a lack of any goal-directed thinking. These limitations in thought may also be manifested as purposeless behavior, such as rummaging or punding A stereotypy is a repetitive or ritualistic movement, posture, or utterance, found in patients with mental retardation, autism spectrum disorders, tardive dyskinesia, frontotemporal dementia[citation needed] and stereotypic movement disorder. Stereotypies may be simple movements such as body rocking, or complex, such as self-caressing, crossing, or as a difficulty completing a single purpose-oriented task - to the extent that a delirious individual may engage in a string of incomplete and unrelated activities.
Disorientation (another symptom of confusion, and usually a more severe one) describes the loss of awareness of the surroundings, environment and context in which the person exists. It may also appear with delirium, but it is not required, as noted. Disorientation may occur in time (not knowing what time of day, day of week, month, season or year it is), place (not knowing where one is) or person (not knowing who one is).
Cognitive function may be impaired enough to make medical criteria for delirium, even if orientation is preserved. Thus, a patient who is fully aware of where they are and who they are, but cannot think because they cannot concentrate, may be medically delirious. The state of delirium most familiar to the average person is that which occurs from extremes in pain, lack of sleep, or emotional shock.
Because most high level mental skills are required for problem solving Problem solving is a mental process and is part of the larger problem process that includes problem finding and problem shaping. Considered the most complex of all intellectual functions, problem solving has been defined as higher-order cognitive process that requires the modulation and control of more routine or fundamental skills. Problem, including ability to focus attention, this ability also suffers in delirium. However, this is a secondary phenomenon, since problem-solving involves many sub-skills and basic mental abilities, any of which may be impaired in a delirious patient.
Memory formation disturbance
Impairments to cognition may include temporary reduction in the ability to form short-term or long-term memory In psychology, memory is an organism's ability to store, retain, and recall information and experiences. Traditional studies of memory began in the fields of philosophy, including technique of artificially enhancing the memory. The late nineteenth and early twentieth century put memory within the paradigms of cognitive psychology. In recent. Difficult short-term memory tasks like ability to repeat a phone number may be continuously disrupted during a delirium, but easier short-term memory tasks like repeating single words, or remembering simple questions long enough to give an answer, may not be impaired. Reduction in formation of new long-term memory (which by definition survive withdrawal of attention), is common in delirium, because initial formation of (new) long-term memories generally requires an even higher degree of attention, than do short-term memory tasks. Since older memories are retained without need of concentration, previously formed long-term memories (i.e., those formed before the period of delirium) are usually preserved in all but the most severe cases of delirium (and when destroyed, are destroyed by the underlying brain pathology, not the delirious state per se).
Abnormalities of awareness and affect
Hallucinations A hallucination, in the broadest sense of the word, is a perception in the absence of a stimulus. In a stricter sense, hallucinations are defined as perceptions in a conscious and awake state in the absence of external stimuli which have qualities of real perception, in that they are vivid, substantial, and located in external objective space. The (perceived sensory experience with the lack of an external source) or distortions of reality may occur in delirium, but they are not essential for the diagnosis. Commonly these are visual distortions, and can take the form of masses of small crawling creatures (particularly common in delirium tremens Delirium tremens ; literally, "shaking delirium" or "'trembling madness" in Latin) is an acute episode of delirium that is usually caused by withdrawal from alcohol, first described in 1813. Benzodiazepines are the treatment of choice for delirium tremens (DT), caused by severe alcohol withdrawal) or distortions in size or intensity of the surrounding environment.
Strange beliefs Belief is the psychological state in which an individual holds a proposition or premise to be true may also be held during a delirious state, but these are not considered fixed delusions A delusion is a fixed belief that is either false, fanciful, or derived from deception. In psychiatry, it is defined to be a belief that is pathological and is held despite evidence to the contrary. As a pathology, it is distinct from a belief based on false or incomplete information, dogma, stupidity, apperception, illusion, or other effects of in the clinical sense as they are considered too short-lived (i.e., they are temporary delusions - such as thinking that a nurse is a person from his/her past trying to cause injury). Interestingly, in some cases sufferers may be left with false or delusional memories after delirium, basing their memories on the confused thinking or sensory distortion which occurred during the episode of delirium. Other instances would be inability to distinguish reality from dreams.
Abnormalities of affect which may attend the state of delirium may include many distortions to perceived or communicated emotional Emotion is the complex psychophysiological experience of an individual's state of mind as interacting with biochemical and environmental influences. In humans, emotion fundamentally involves "physiological arousal, expressive behaviors, and conscious experience". Emotion is associated with mood, temperament, personality and disposition, states. Emotional states may also fluctuate, so that a delirious person may rapidly change between, for example, terror, sadness and jocularity.
Duration
The duration of delirium is typically affected by the underlying cause. If caused by a fever, the delirious state often subsides as the severity of the fever subsides. However, it has long been suspected that in some cases delirium persists for months and that it may even be associated with permanent decrements in cognitive function. Barrough said in 1583 that if delirium resolves, it may be followed by a "loss of memory and reasoning power." Recent studies bear this out, with cognitively normal patients who suffer an episode of delirium carrying an increased risk of dementia in the years that follow. In many such cases, however, delirium undoubtedly does not have a causal nature, but merely functions as a temporary unmasking with stress, of a previously unsuspected (but well-compensated) state of minimal brain dysfunction (early dementia).
Causes
Delirium is a very general and nonspecific symptom of organ dysfunction, where the organ in question is the brain. In addition to many organic causes relating to a structural defect or a metabolic problem in the brain, there are also some psychiatric causes, which may include a component of mental or emotional stress, or mental disease.
Delirium may be caused by physical illness, which can be mild, or any process which interferes with the normal metabolism or function of the brain.[6] For example, fever Fever is a common medical sign characterized by an elevation of temperature above the normal range of 36.5–37.5 °C (98–100 °F) due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering, pain Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It is the feeling common to such experiences as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone", poisons In the context of biology, poisons are substances that can cause disturbances to organisms, usually by chemical reaction or other activity on the molecular scale, when a sufficient quantity is absorbed by an organism. Legally and in hazardous chemical labeling, poisons are especially toxic substances; less toxic substances are labeled " (including toxic drug In the United States, the FDA approves drugs. Before a drug can be prescribed, it must undergo an extensive FDA approval process. This process involves first testing the drug on animals or in medical labs. If found to be safe by the FDA and approved for the next phase of study, the drug is then tested for safety and effectiveness in humans . The reactions), brain injury, surgery, traumatic shock, lack of food or water or sleep, and even withdrawal symptoms of certain drug and alcohol An alcoholic beverage is a drink containing ethanol . Alcoholic beverages are divided into three general classes: beers, wines, and spirits dependent states, are all known to cause delirium.
In addition, there is an interaction between acute and chronic symptoms of brain dysfunction; delirious states are more easily produced in people already suffering with underlying chronic brain dysfunction.[7]
A very common cause of delirium in elderly people is a urinary tract infection, which is easily treatable with antibiotics, reversing the delirium.
Too many to list by specific pathology, major categories of the cause of delirium include:
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