Alan T. Bates, MD, PhD and Yesne Alici, MD December 20, 2014
Delirium is a mental disorder from which no one is immune. Because, if you're unlucky, even the right set of medications prescribed by a doctor can cause attention problems, disorientation and psychosis in any of us.
However, despite the universality of the risk, relatively high prevalence and potential long-term consequences, the topic of delirium is nowhere addressed; there are no public groups dedicated to promoting, preventing, or even informing humanity about the seriousness of the disorder. Even in medicine, delirium cannot find a home. Describing this pathology in 1959, Engel and Romano placed it somewhere between the field of internal medicine and the field of psychiatry: “... by an unfortunate coincidence, the topic of brain disturbances in delirium has been suspended between the interests of internists and psychiatrists...”.
The situation has not changed much since then, but modern developments in psychosomatic medicine, as well as wider recognition of the negative consequences of delirium by the medical and surgical communities, have helped to accelerate progress in this direction. The American Delirium Society and the European Delirium Association are examples of organizations working to bridge the gap between medical fields regarding delirium. Advances in the prevention and treatment of delirium will not happen overnight; and delirium promises to burden the healthcare system with “dementia-related costs” for a long time to come. Meanwhile, more and more evidence is accumulating in support of Engel and Romano's seemingly prescient claim that delirium “...carries a serious risk of permanent and irreversible brain damage.”
Diagnosis: from DSM-IV to DSM-5
The DSM-IV diagnostic criteria for delirium can ultimately be reduced to impairments of consciousness (eg, changes in orientation or attention) associated within this clinical entity with other cognitive impairments (eg, memory, language disorders) if they are not the result of dementia. The next criterion is a relatively acute onset with fluctuations in the severity of symptoms throughout the day; and the last criterion: delirium is usually caused by some disease (for example, pneumonia).
As has been the case with many other diagnoses, delirium has become the subject of much debate: what changes should be made to the DSM-5? After all, the differences between DSM-IV and DSM-5 are very small. As a result, the DSM-5 omits the vague concept of “consciousness”; the emphasis is placed directly on disturbances of attention and orientation. This clearly differentiates, for example, delirium and coma; less successfully - delirium and dementia (a disorder that is most often combined with delirium).
Clinical manifestations
The initial stage of delirium is characterized by the appearance of the main precursors of the disease - anxiety, severe insomnia, increased sensitivity of the auditory and visual analyzers. The patient experiences mood swings during the day and has nightmares, from which he wakes up in a cold sweat. Even before falling asleep, lying with your eyes closed, vivid hallucinations appear.
The main symptom is impaired consciousness. The severity of the disorder varies greatly during the day - clinical manifestations subside during the day, becoming brighter in the evening. This sign is important when diagnosing delirium, so it is important for the patient’s relatives and friends to closely monitor his behavior. In 30% of cases, a generalized seizure (convulsion) occurs.
During the daytime, consciousness may return completely - for a period of from several minutes to several hours. As the symptoms intensify, the person no longer understands where he is. Concentration decreases. In this case, the patient unmistakably answers what his name is, how old he is, and what profession he has.
Impaired perception manifests itself in threatening visions and illusions - the patient may feel that the wallpaper pattern is turning into a snake, etc. He perceives quiet voices in the next room as the roar of a crowd. Hallucination characters evoke intense fear. Real people practically do not attract the patient's attention.
Emotions change throughout the day. Anxiety is accompanied by trembling of the arms, legs and head, and muscle tension. Breathing and heart rate increase. During attacks, behavior is characterized by either inhibition or agitation.
The patient speaks in abrupt, monosyllabic sentences. In his speech it is easy to discern descriptions of hallucinations. Delusions are often associated with persecution. Muscle weakness and unsteady gait are prominent symptoms of delirium.
There is no ability to remember recent events. Long-term memory is retained. During attacks there is no critical attitude towards one’s own condition. After recovery, memories of hallucinations and nightmares are partially preserved.
Symptoms of delirium include rough tremor (shaking) of the limbs, restlessness of movements, and increased body temperature. The patient sweats profusely and goes to the toilet frequently. Urine is released in small volumes.
With a mild course, random wandering thoughts appear. During moments of clouding of consciousness, the patient utters incoherent statements. This form is often called quiet delirium and is considered difficult to differentiate from other disorders of consciousness - when it is necessary to make an accurate diagnosis, ruling out many possible diseases.
Delirium as a syndrome
Meagher et al attempted to describe delirium as a syndrome in detail using a sample of 100 patients receiving palliative care for their disorder. Some of the most common signs and symptoms they identified are the same as those mentioned in the DSM-5:
• Attention disturbance (97% of patients)
• Deterioration of long-term memory (89%)
• Deterioration of short-term memory (88%)
• Disorientation (76%)
• Decreased ability for spatial-visual orientation (87%)
• Speech disorders (57%)
• Perceptual disturbances (50%)
Since hallucinations are the symptom that most often brings patients to a psychiatrist, it is worth noting that at least half of the patients denied their presence.
The results of this study highlight other pitfalls in the path of the clinician dealing with delirium disorder. Physicians in medical records usually abbreviate phrases regarding activity and disorientation in self, place and time, replacing them with shorthand: “A&O ? 3” (“alert, oriented to person, place, and time” = “active, oriented to person, place and time”). Even if this record reflects a thorough examination of disorientation, 25% of the patients in the sample show abnormalities on at least one item. Meagher and colleagues also reported sleep-wake cycle disturbance (97%), motor agitation (62%), and retardation (62%) as common symptoms, although these symptoms are not listed among DSM-5 criteria. The fact that each of these three symptoms—in addition to their widespread prevalence—occurs in the early stages of delirium reflects their important clinical significance. Common signs and symptoms of delirium are listed in Table 1.
Variants of the course and differential diagnosis of delirium
One of the most common discussions between clinicians after evaluating the same patient is whether the patient is confused or cognitively intact. The wave-like nature of the course of delirium can lead to the fact that the patient during the examination reveals, for example, exceptional clarity of mind, and after a few hours finds himself completely disorganized and disoriented. Instead of serving as a basis for suspecting colleagues of incompetence, these polar assessments should have been accepted as important diagnostic information.
In addition to fluctuating course, acute onset, attention deficits, and sleep-wake fragmentation, several other features may help differentiate delirium from dementia (Table 2). However, the differential diagnosis of delirium and severe forms of dementia may be more difficult than described in textbooks. Features of dementia with Lewy bodies, including orientational fluctuations and visual hallucinations, make differential diagnosis particularly problematic. It is even more difficult to determine whether dementia is present in the context of delirium, since symptoms of delirium tend to mask symptoms of dementia that would be more obvious without delirium.
Another factor that complicates the differentiation of delirium and other disorders is the variety of types of delirium. The latter can occur in the form of hyperactive, hypoactive, or mixed (the presence of symptoms of both hyperactive and hypoactive) types; this increases the ability of delirium to mimic. The fact that delirium is often misdiagnosed as depression reflects the similarity of some of the symptoms of the two conditions, including psychomotor retardation, decreased motivation, and sedation. At the other end of the spectrum of delirium symptoms are anxiety, psychomotor agitation, and hallucinations in hyperactive delirium; and this may lead clinicians to suspect anxiety disorders, mania, or exacerbation of chronic psychosis as possible causes of the condition.
Regardless of the type - hypoactive, hyperactive, or mixed, delirium differs from all other disorders in the way it develops and flows (acute rather than gradual onset; undulating rather than continuous course), which provides clues to the correct diagnosis of this syndrome. Another feature worth noting that is important in differentiating delirium from other psychotic disorders (such as schizophrenia) is that delirium is characterized by visual rather than auditory hallucinations.
Other forms of delirium tremens
- Abortive. Lasts several hours, hallucinations with preservation of orientation are typical.
- Hypnagogic. Illusions occur at night, during sleep, and persist for half an hour after waking up.
- With a predominance of auditory hallucinations and delusions of persecution.
- Atypical. Accompanied by an altered perception of the body diagram. An alcoholic is sure that his internal organs are being taken out and his thoughts and subconscious are being controlled. Concomitant somatic clinical signs are strongly expressed.
- Fantastic (alcoholic oneiroid). Delusions and visions of fantastic content, delusions of grandeur (often ridiculous - the patient imagines himself as a captain of a spaceship, a great commander, etc.) are typical.
Rating scales
Rating scales may have a role in differentiating delirium from other disorders and in monitoring response to therapy. Although there is no single generally accepted scale for diagnosing delirium, the Mini-Mental State Examination (MMSE) is most often used for this purpose. This scale provides a rough assessment of a range of cognitive functions such as orientation, language, numeracy and memory. However, the MMSE does not differentiate delirium from other causes of cognitive dysfunction, although deficits in various cognitive domains may certainly be caused by other specific lesions or deficits.
The Montreal Cognitive Assessment (MoCA) has similar shortcomings, although many clinicians have begun to use it instead of the MMSE for brief cognitive screening. MoCA has greater sensitivity in detecting mild cognitive impairment and provides better assessment of frontal cortex functions, including executive functions, abstract reasoning, and word generation. This scale is free and available for clinical use in several languages at www.mocatest.org.
Several rating scales for delirium have been developed, and each has its own advantages and disadvantages. The Confusion Assessment Method (CAM) is used probably because of its simplicity. It contains only 4 points (acute onset and wave-like course; decreased level of attention, and either disorganized thinking or a change in the level of consciousness); that is, this scale can be used to assess a patient's condition by nurses and other health care personnel with less training in psychiatry. While the relative simplicity of CAM allows it to be used for screening large numbers of patients in non-psychiatric areas of medicine, its sensitivity may depend largely on the individual experience of the examiner.
Ely et al adapted the CAM scale for use in mechanically ventilated patients in intensive care units and named the CAM-ICU scale. However, some caution must be exercised when using the CAM-ICU outside the specific IT department environment, because in these cases it is not sensitive enough.
The Delirium Rating Scale-Revised-98 (DRS-R-98), which includes 13 severity criteria and 3 diagnostic criteria, can be used to differentiate delirium from dementia, depression, or schizophrenia; and also to assess the severity and record the phenomenological features of a particular case for clinical or research purposes. This scale is usually used by doctors with psychiatric training.
The Memorial Delirium Assessment Scale (MDAS) is also intended for use by clinicians with more advanced training. The MDAS, which was originally approved for use with patients with advanced cancer or AIDS, was designed to be administered repeatedly over the same day, thereby providing an assessment of the patient's progress in response to therapy or medical procedures.
Despite the fact that the diagnosis often indicates one or another subtype of delirium, even the most comprehensive rating scales, as a rule, contain only 1 or 2 items aimed at differentiating these subtypes (for example, in the DRS-R-98 scale - item 7: “Motor agitation” and item 8: “Motor retardation”; in the MDAS scale – item 9: “Decreased or increased psychomotor activity”). While rating scales are very valuable and can be useful clinical tools, the gold standard for obtaining information about attentional fluctuations remains a thorough clinical assessment, supplemented by information from family and medical personnel.
Diagnostics
Delirium is diagnosed for a certain period of time sufficient to identify cognitive impairment (memory, thinking, speech) and level of consciousness. A short test of attention, memory and concentration allows you to quickly assess the functionality of the brain. The patient is asked his name, location, year and exact date. To assess short-term memory, it is suggested to remember the name and address. The data is repeated several times until the person names them himself.
Concentration is checked by counting backwards from 20 to 1, and then listing calendar months in reverse order. When completing the test, the patient says his name and address again. During the interview, the specialist monitors eye movements - when illusions and hallucinations appear, a person may stare intensely into the void, sharply turn his head, or pull the blanket. The doctor also interviews loved ones.
The Hamilton scale is used to assess depression. For a manic state (accelerated speech and thinking, motor agitation, elevated mood), the Young Mania Scale is used.
Stress for patients, their families and medical staff.
Delirium is often a very frightening experience for patients, their families and friends. It can also make nursing care difficult or even dangerous. Breitbart and colleagues found severe delirium-related distress among hospitalized cancer patients, as well as their spouses, caregivers, and nurses. The presence of delusional disorders was the strongest predictor of distress in patients with both hypoactive and hyperactive delirium.
Jones and colleagues demonstrated an association between delusional memories and PTSD in ventilated patients in intensive care units. Overall, they found that 9.2% of previously mechanically ventilated patients in intensive care units developed associated PTSD 3 months after weaning from the ventilator.
Long-term consequences
Although it is difficult to definitively trace cause and effect, there is growing evidence that delirium is associated with long-term cognitive decline. Bickel et al examined cognitive function in 200 patients over 60 years of age 38 months after hospital discharge for hip surgery. In 41% of cases, patients experienced postoperative delirium. During follow-up, the MMSE score was below 24 in 54% of patients who experienced delirium and only 4% of those who did not. Processing the study results using logistic regression - taking into account the age, gender, concomitant disease and preoperative level of cognitive function of patients - revealed a significant association between the experience of delirium and existing cognitive deterioration, subjective memory loss and the need for long-term care.
Meta-analysis results show that in older patients, delirium is associated with an increased risk of death (38% versus 28% in the control group) at a mean follow-up of 23 months, and an increased risk of social maladjustment (33% versus 11%) at a mean follow-up of 15 months. , and an increased risk of dementia (63% versus 8%) over a median follow-up of 4 years. Studies included in the meta-analysis certainly took into account additional factors such as age, gender, comorbidity, severity and premorbid dementia.
More recently, Pandharipande and colleagues assessed cognitive decline in patients with respiratory failure or shock who required intensive care in their study. The researchers found that delirium developed in 74% of the 821 people who took part in the experiment. At 12-month follow-up, 34% of patients in this sample had cognitive function at the same level as patients with moderate traumatic brain injury, and 24% had levels consistent with mild Alzheimer's disease. Longer duration of delirium correlated with more severe cognitive dysfunction in prognosis.
Typology of disorders of consciousness
Disorders of consciousness are extremely heterogeneous, ranging from inhibition to excitation [18], in extreme cases of inhibition at times approaching comatose states, and in extreme cases of excitation resembling schizophreniform psychoses. Cognitive disorders also vary in severity, including both forms of cognitive impairment that are limited to attention disorders and forms with transient “focal” cognitive deficits.
Psychiatrists who have studied the clinical features of somatogenic psychoses have described a variety of manifestations of disorders of consciousness. In a systematic analysis of symptomatic psychoses, K. Bonhoeffer [19] distinguished delirious, amental and twilight disorders of consciousness. Following him, E. Kraepelin [20] mentioned delirium and amentia as manifestations of parainfectious psychoses. In later classifications, amentia could be classified as a type of delirium [4], which was confirmed by early observations that identified forms of delirium with more pronounced cognitive fragmentation [19]. Recent work conducted with the participation of a contingent of elderly patients in a multidisciplinary hospital [21] revealed several types of confusion, including delirium (37.9%), amentia (18.7%) and forms of confusion with confabulation (11.8%), approaching Korsakov's syndrome.
Despite the fact that the boundaries between different types of disorders of consciousness are blurred, the creation of a clinical typology has not only scientific, but also practical value. First, it equips the researcher with a more sensitive diagnostic tool that can capture individual differences while at the same time integrating them into delineated nosological units. Secondly, attention to various clinical manifestations allows us to evaluate their prognostic significance.
Another trend (and so far the prevailing one) is to follow the syndromic and statistical classification, which, without making a nosological distinction, combines a variety of post-stroke clouding of consciousness into the group F05.x “Delirium not caused by alcohol or other psychoactive substances” [22]. But even with a syndromic approach, clinical needs force us to consider syndromes that go beyond the usual somatogenic psychoses: for example, evening confusion in patients with dementia [23, 24].
Although foreign works do not distinguish between delirious, oneiric and amentive disorders of consciousness, such a distinction is of great practical importance, since different syndromes may have different etiologies and prognosis. Thus, delirious and oneiric symptoms are often found in infectious-toxic diseases [25].
The creation of a clinical typology for patients with brain damage primarily pursues a pragmatic goal - to distinguish disorders directly related to damage to certain structures from disorders the appearance of which is caused by secondary factors (biochemical post-ischemic cascade or intoxication of a somatic nature).
In this regard, the approach of the Russian neuropsychiatric school, which is used to classify the consequences of traumatic brain disease, is interesting [26]. The authors separate the syndromes of stupefaction (delirium, oneiroid, twilight changes in consciousness) from various forms of confusion (amnestic, amnestic-confabulatory, speech, etc.). The presence of confusion reflects predominantly the disintegration of cognitive functions (and certain damage to brain structures), while delirium and oneiroid are manifested by disorientation, closely associated with hallucinatory-delusional symptoms (and secondary toxic brain damage).
Mortality
In at least some cases, delirium has been associated with premature death in patients. In a controlled study of baseline cognitive function, physiological function level, and general health status, Curyto et al found that delirium in hospitalized older adults was significantly associated with an increased mortality rate at 3 years after hospitalization (75% vs. 51% in the control group). ). The same negative association was seen between delirium and mortality in elderly patients. The development of delirium in mechanically ventilated patients in the intensive care unit also appears to be a very poor prognostic sign. In elderly intensive care unit patients, the risk factor appears to be not only the occurrence of delirium, but also its duration.
How to recognize delirium tremens?
The symptoms of delirium tremens are described in the Latin name for this disease: delirium tremens, which literally means “shaking darkness.” The two main signs of psychosis are: clouding of mind and trembling of the whole body.
In drug treatment circles, it is customary to divide fever into three stages. Symptoms appear 2–3 days after quitting binge drinking and gradually increase over the course of a week. Most addicts come out of delirium tremens acutely, falling into a long, deep sleep, but some can come out of it gradually.
In the first, the patient suffers from mood swings. He experiences anxiety, which gives way to a state close to euphoria. Anxiety attacks become longer, hand tremors are observed, and the rate of speech accelerates. The person looks either pale and anxious, or unnaturally joyful.
At the second stage, hallucinations occur. They begin at the moment of falling asleep, giving way to nightmares. A person cannot separate nightmares and reality, which is why even after waking up he sees insects, monsters, maniacs, strangers and animals, and mythical creatures. Some alcoholics feel that their relatives want to harm them, while others, on the contrary, try to protect their loved ones from an imaginary danger. Over time, insomnia comes, but the intensity of hallucinations only increases.
The third phase is the exit from psychosis. Most often, a person comes out of delirium quite abruptly, falling into a long sleep. Subsequently, the patient feels tired and may suffer from hypomania or depression. Typically, an alcohol addict remembers hallucinations well, but has difficulty telling what was a figment of his imagination and what actually happened.
Prevalence and incidence
An analysis of survey data from the East Baltimore Mental Health Review found that the prevalence of delirium in the community increases significantly with advancing age: 0.4% in patients over 18 years of age and 1.1% in patients over 55, but the rate is increasing up to 13.6% in patients over 85 years of age. Delirium can also develop in children. In pediatric practice, delirium develops in at least 30% of seriously ill children.
In persons over 75 years of age in nursing homes, the prevalence of delirium may approach 60%. There is also evidence of a high incidence of delirium in persons undergoing emergency medical intervention. The postoperative period is especially dangerous in this regard. Cardiac surgery is more likely to cause delirium than other types of surgery. The results obtained by Rudolph and colleagues call the incidence of delirium after cardiac surgery in patients over 60 years of age: 52%. Up to 70% of patients who require intensive care unit admission experience delirium at some point during their admission; and the incidence of delirium reaches 88% in patients with end-stage diseases.
Risk factors
Knowing the risk factors for delirium is important for 2 reasons. First of all, it can help predict the risk of developing delirium in the future. For example, the presence of multiple risk factors in the preoperative period might mean the need for prior consultation with a psychiatrist for complete postoperative monitoring. Elimination of the disease that may contribute to the development of delirium is the most radical way to treat it; for this reason, knowledge of the risk factors for its development helps to eradicate the main causes of delirium (Table 3).
Many researchers have attempted to identify premorbid risk factors that might predict (and hopefully prevent) delirium. There have been attempts to develop an algorithm that would standardize such a procedure. Despite the fact that certain risk factors in many studies have traditionally been assigned the role of the most threatening in terms of the development of delirium, there are still known discrepancies between the data of various studies. This is partly because the studies are conducted on dissimilar samples (for example, postoperative patients in one case and nursing home residents in another).
One of the most studied samples is patients of cardiac surgery clinics. Giltay et al collected data on 8139 patients who underwent coronary artery bypass grafting and/or artificial heart valve implantation. They found that postoperative psychosis was associated with preoperative factors such as age, renal failure, dyspnea, heart failure, left ventricular hypertrophy; and also with perioperative factors: hypothermia, hypoxemia, low hematocrit, renal failure, high blood sodium levels, infection and stroke. Unfortunately, despite the large sample size, the study did not identify a definitive list of key risk factors.
In a review of risk factors for delirium in heart surgery patients, Sockalingam and colleagues identified a long list of risk factors, ranging from the expected, such as opioid use, to the unexpected, such as marital problems. Here's an example of how risk factors vary across samples. Inouye et al described dementia, visual impairment, functional impairment, high comorbidity, and use of physical restraints as the most important risk factors for the development of delirium in older patients.
Outpatient
The second part of the therapy can be done at home. Recovery takes place under the supervision of a specialist. Therapy includes:
- A calm atmosphere and establishing contact with others. At home, the patient should be given attention, not disturb him unnecessarily and not cause negative emotions. It is important not to raise your intonation or provoke conflict. Initially, the patient may experience frequent mood swings, aggression, and tearfulness. Occasionally, a distortion of reality is recorded.
- Elimination of factors that provoke the condition. The drug that causes psychosis should be immediately removed from the patient’s field of vision. If the cause was delirium tremens, you should give up any alcoholic beverages and undergo coding. If a factor cannot be excluded (for example, a systemic disease), then it is worth minimizing its consequences by continuing therapy as indicated.
- Psychotherapy. To restore the ability to think and soberly assess the situation, as well as to track dynamics, it is recommended to continue psychotherapy. Group and individual lessons help.
- Healthy lifestyle. Lifestyle also plays a certain role. It is especially important to give up smoking, drugs, alcohol and monitor your sleep patterns. To some extent, normalization of nutrition has a beneficial effect.
Many experts talk about the beneficial effects of reflexology, massage, and swimming. With timely treatment, proper treatment and compliance with recommendations, complete remission is usually observed.
Pathophysiology
Maldonado, in his reviews, brought together everything that is known about the pathophysiology of delirium. He summarized the known theories and created several hypotheses: neuroinflammatory, oxidative stress, neurotransmitter deficiency, neuroendocrine, circadian dysregulation, network uncoupling and neuronal aging.
The neuroinflammatory hypothesis proposes that systemic inflammatory processes caused by infection or surgery trigger an inflammatory response in the brain. Evidence includes a study by de Rooij and colleagues, who found elevated cytokine levels in patients with delirium even after infection, age, and cognitive deficits were taken into account.
The oxidative stress hypothesis views delirium as a consequence of fundamental damage to brain metabolism with a lack of oxygenation, which leads to delirium disorder.
The neurotransmitter deficiency hypothesis is likely the best known and most basic. She describes delirium as a disorder associated with a deficiency of acetylcholine and an excess of dopamine. This theory is likely most closely related to clinical practice, since doctors who deal with delirium first of all try to find anticholinergic drugs among patients' medications and stop them. In addition, dopamine-blocking antipsychotics are standard pharmacological treatments for delirium.
The neuroendocrine hypothesis focuses primarily on the effects of elevated glucocorticoid levels observed during physiological stress. At Memorial Sloan Kettering Cancer Center, we routinely see patients who develop delirium in response to external glucocorticoids as part of chemotherapy regimens or to limit the side effects of drugs used to treat cancer.
The circadian dysregulation theory points to a link between delirium and disrupted sleep, and points to the fact that insufficient sleep usually precedes the onset of delirium.
The “network disconnect” hypothesis uses a systems neuroscience approach to explain the pathophysiology of delirium and incorporates evidence from modern imaging techniques, including functional MRI, of poor coordination between different parts of the brain.
The neuronal aging hypothesis combines aspects of several other hypotheses and provides a pathophysiological rationale for the fact that older patients are more susceptible to delirium. Maldonado emphasizes that there are "areas of overlap" between the main hypotheses and views them primarily as complementary rather than competing.
Stationary
The first aid for delirium is 24-hour hospitalization. In Moscow and other Russian cities, doctors are successfully fighting the condition and its consequences. Recovery is mainly achieved through a combination of medication and psychotherapy. The following stages are expected:
- Detecting causes and prescribing appropriate therapy;
- Minimizing the amount of medications taken;
- Detoxification is carried out if necessary;
- Creating a favorable and calm environment;
- Relieving disorientation in space, time and society;
- Drawing up a recovery plan for the body.
Before starting therapy, it is necessary to diagnose the brain using X-rays. The method of magnetic resonance or computed tomography allows identifying a condition of traumatic, organic etiology, as well as vascular, the treatment of which is important to begin immediately. Additionally, it is necessary to conduct a general blood and urine test. Laboratory tests make it possible to assess the patient’s condition, detect intoxication, inflammation, and symptoms of renal failure. The department of the hospital that treats delirium becomes specialized for the main diagnosis: narcology, gastroenterology, urology, nephrology.
Securing the patient should be strictly avoided. This leads to aggravation of the stage, the patient suffers and becomes nervous. Limb binding is used only in cases of life-threatening situations (suicide attempt) or during periods of aggression.
Non-drug prevention and treatment
In a study of 852 elderly patients admitted to a network of general hospitals, it was possible to reduce the incidence of delirium from 15% to 9% using a number of non-pharmacological measures, for example, frequent reorientation of patients, participation in cognitively stimulating activities, sleep induction with specific stimuli (eg , relaxation tapes, drinking warm milk), as well as using a sleep-promoting environment (eg, reducing noise), encouraging physical activity, using visual and auditory devices (eg, glasses, portable amplifiers), and early management of dehydration.
Although pharmacotherapy for delirium in elderly patients should be considered as a last resort after non-pharmacological approaches, most medical and surgical departments do not provide a therapeutic environment for patients (Inouye et al). Although it is clear that the most effective measures used to reduce the number and severity of delirium may be environmental changes in hospital wards and changes in the behavior of nursing staff.
Drug prevention
To date, the prophylactic use of antipsychotics in surgical patients has been studied little. Of the studies using haloperidol for this purpose, two found a reduction in the incidence of delirium, while the third only showed a reduction in the duration of delirium. There is some evidence that prophylactic use of risperidone and olanzapine reduces the incidence of postoperative delirium, and a meta-analysis shows that prophylactic use of antipsychotics reduces the incidence of delirium by half.
Prevention of delirium in intensive care units has not been as successful. In a sample of mechanically ventilated intensive care unit patients, there was no difference between haloperidol and placebo. Using a completely different pharmacological strategy, Al-Aama and colleagues found that in patients over 65 years of age who were hospitalized in intensive care units, the incidence of delirium was reduced by prophylactic use of melatonin.
Thus, there is evidence of the effectiveness of the use of antipsychotics to prevent the development of delirium in the postoperative period, but not in patients in intensive care units. Further research has confirmed the effectiveness of alternative strategies such as the use of melatonin.
conclusions
Delirium is an acute condition with sudden development, having a different etiology. It causes persistent changes in consciousness, major disruptions in vital activity and is life threatening. Patients are not aware of their actions; such mental disorders can traumatize others. The effectiveness of delirium treatment is based on the emergency adoption of somatic measures, minimizing pharmacological therapy, and creating a trusting atmosphere. Only specialists can provide first aid, carry out separate measures, and guarantee recovery. It is strictly forbidden to fight psychosis on your own or not take any measures.
Pharmacotherapy
Pathogenetic therapy for delirium involves eliminating its causes, which often requires the use of medications (for example, antibiotics to treat urinary tract infections). In addition, certain symptoms of delirious disorder are relieved with medication. Some researchers argue that symptom therapy serves only to reduce suffering and ensure the safety of the patient, visitors, and staff. Others point to the long-term consequences of delirium and suggest that treatments that reduce the severity and/or duration of delirium also reduce the risk of subsequent cognitive deficits.
Among the antipsychotics used to treat delirium, haloperidol is the most commonly used. A drug with potent dopamine antagonism and weak anticholinergic effects, haloperidol is a logical choice for treating a disorder thought to be associated with a hyperdopaminergic/hypocholinergic state. Other advantages of this drug include its potential for intravenous administration and lack of serious effects on the autonomic nervous system. However, when comparing the effectiveness of known antipsychotics against delirium, no difference was found between them.
• Chlorpromazine and risperidone were equally effective with haloperidol in a randomized, double-blind trial.
• No significant differences were found between olanzapine and haloperidol or risperidone in a randomized, blinded trial
• Quetiapine reduced the duration of delirium compared with placebo in a randomized, double-blind trial.
• No significant differences were found between aripiprazole and haloperidol in a non-randomized open-label study
When choosing a drug, it is best to be guided by the specific status of a particular patient. For example, quetiapine may be a good choice for the treatment of delirium in patients with Parkinson's disease.
It should be noted that completely different tactics must be used to relieve alcoholic delirium. The history of the search for this tactic is beyond the scope of this review, but, as a rule, the use of benzodiazepines is indicated in such a situation. Unfortunately, delirium delirium can be difficult to distinguish from other types of delirium. Factors that aid in the differential diagnosis of delirium tremens include a significant history of alcohol use, history of abstinence, and laboratory tests that support alcohol abuse (eg, positive blood alcohol test, elevated β-glutamyltransferase (GGT), elevated carbohydrate-deficient transferrin (CDT). , change and increase in the AST/AlAT ratio, increase in mean blood cell volume (MCV)), instability of vital functions, sweating and tremor.
Causes of delirium and risk groups
As a rule, delirium develops either due to alcohol, delirium tremens - delirium tremens, or due to drug use, or due to neurological diseases - stroke or dementia. This is a condition that occurs against the background of a strong external or internal influence on the human brain. The body reacts to this influence with very intense symptoms of psychosis.
If delirium begins due to alcohol or drugs, it can usually be stopped within a few days, except in some cases where the person is genetically predisposed to such psychoses.
Delirium tremens most often develops after 5-7 years of regular drinking of large amounts of alcohol. However, it can develop after less time. It all depends on genetic factors, predisposition and brain disorders of a person. It can also occur after a sudden cessation of substance use, including after a long binge. People who do not suffer from chronic alcoholism develop delirium less frequently. Delirium tremens is sometimes confused with the altered state in which a drunk person is. In fact, delirium develops after stopping alcohol consumption, as a continuation of withdrawal syndrome - withdrawal during addiction. Those at risk for psychosis include people who have suffered severe central nervous system disease or traumatic brain injury. For those who have had delirium tremens in the past, psychosis may recur even with small amounts of alcohol.
Family education
It is very good if there is no obvious conflict between the patient and his family members. A relative at the patient's bedside can provide invaluable assistance both in diagnosis and in the treatment process. It is family members who provide constant reorientation and support to the patient, and they also help the patient meet immediate needs. Unfortunately, family members usually know little about delirium, which can lead to defensive reactions to the doctor's efforts to diagnose and treat their ill relative (eg, “You don't understand. He's not crazy. He doesn't need a psychiatrist!”).
Gagnon et al found that training family members to understand delirium increased their trust in health care procedures and interventions. Similarly, Otani and colleagues reported that 81% of family members found that they benefited from receiving a leaflet that included information about the nature and treatment of delirium.
Although patients' relatives may not know anything about delirium, they are often the first to notice that "something is wrong" with the patient. Steis et al found that family members may be helpful in more formalized assessments of delirium disorders. Researchers showed that family caregivers using the Family Assessment of Confusion Method (FAM-CAM) demonstrated 88% sensitivity and 98% specificity in identifying delirium using CAM as the diagnostic standard.
There are a number of educational websites dedicated to the topic of delirium, which can certainly be of benefit to both families and those doctors who, due to their line of work, rarely encounter this disorder. www.thisisnotmymom.ca is an example of a site that demonstrates the important role of family members and also provides case examples that can help guide clinicians.
Treatment options for delirium
Treatment of delirium involves an integrated approach aimed at getting rid of the cause and stopping behavioral disorders. There are medical non-drug and pharmacological methods of therapy. Typical use:
- Non-drug methods. The group includes various psychotherapeutic techniques, cognitive stimulation, and verbal techniques. Communication with family and loved ones plays an important role. It is recommended to maintain a balance between stimulation and calming: it is advisable to reduce any stimulating actions to a minimum.
- Drug therapy is common. The classic scheme involves the use of antipsychotics, antidepressants, and sedatives. Combinations, dosages and prescriptions are related to etiology.
Some forms of delirium (pharmacological, alcoholic, drug) should be treated without drugs or with a limited number of drugs. Excess chemicals can worsen psychosis.
Directions of development
Compared with disorders such as schizophrenia or depression, delirium has always attracted relatively less clinical and research interest in psychiatry. Unfortunately, just as little attention is paid to it in emergency medicine, resuscitation, surgery, and other areas where delirium, nevertheless, is a very common phenomenon. This historical neglect represents enormous potential for advances in research and clinical practice that will ultimately lead to significant benefits for patients.
The complex pathophysiology of delirium and the wide range of variability in clinical symptoms suggest that it is possible to study the effects of different drugs on different physiological processes and tailor therapy to each individual patient. Instead of serving as an obstacle to care, delirium should become an area of cooperation between psychiatrists, neurologists, resuscitators, surgeons, geriatricians, and doctors of other specialties. Researchers involve various medical specialists to solve the problems they face; They integrate in their work the methods of genetics, clinical neurophysiology, psychopharmacology, and neuroimaging. We can firmly count on the fact that in the near future they will lead us to a better understanding of the work of attention and the cognitive sphere both in healthy people and during illness.
Based on materials from the site: https://www.psychiatrictimes.com/
All materials on the site are presented for informational purposes only, approved by a certified physician, Mikhail Vasiliev, diploma series 064834, in accordance with license No. LO-77-005297 dated September 17, 2012, a certified specialist in the field of psychiatry , certificate number 0177241425770.
Why is delirium tremens dangerous?
The consequences of fever are terrible - these include mental disorders, neurological pathologies, metabolic disorders, and severe damage to the liver and kidneys. A person suffering from cardiovascular disease may simply not survive prolonged and painful delirium, which exhausts him physically and psychologically.
Another danger of delirium is the risk that an alcohol addict, under the influence of hallucinations and paranoia, will harm loved ones. For example, alcoholic delusions of jealousy are quite common, when the patient - most often a man - begins to suspect his wife of infidelity. Usually, delusions of jealousy develop over some time: first, the addict suspects his wife of infidelity while drunk, then the delirium spreads to moments of hangover and even sobriety. Often the paranoia is frankly ridiculous, but the patient is completely convinced that he is right. During delirium, plausible hallucinations may join paranoia: the imagination pictures lovers right in the apartment.
It's easy to imagine what this might lead to. In such situations, wives, children, and innocent “lovers” often suffer.
