What is Delirium?
Delirium (insanity lat.) – a mental disorder that proceeds with a violation of consciousness (from the darkened state to coma). It is characterized by an influx of bright, mostly visual, hallucinations and illusions, obstructed by orientation in the surrounding world, disoriented in time. At the same time self-awareness is preserved. The emotional state of the patient depends on the nature of the hallucinations.
Lindesay (1999) reports that the term “delirium” was introduced by an ancient Roman scholar named Aulus Cornelius Celsus in the 1st century AD. e.
In modern interpretation, the concept of “delirium” has lost its former psychopathological content, as a qualitative disorder of consciousness with true, mostly visual, hallucinations. The delirium clinic, according to the modern classifications of mental disorders ICD-10 and DSM-IV, includes a variety of conditions that are traditional for the domestic psychopathology of both qualitative (actually delirium, amentia, oneiric) and quantitative (stunning, spoor, coma) disorders of consciousness, as well as him impaired cognitive and other mental functions.
Causes of Delirium
The main causes of delirium and confusion
- Therapeutic or surgical diseases (no signs of foci or lateralization, cerebrospinal fluid unchanged):
– Postoperative (hypoxia) and postcommutable states.
– Diseases accompanied by fever: pneumonia, typhoid fever, malaria, streptococcal septicemia, rheumatism.
– Thyrotoxicosis and ACTH poisoning (rare). - Neurological diseases leading to symptoms of foci or lateralization or changes in the cerebrospinal fluid:
– Vascular, neoplastic or traumatic lesions, especially of the temporal lobes and upper brain stem.
– Acute bacterial or tuberculous meningitis.
– Subarachnoid hemorrhage.
– Viral encephalitis or mepingoencephalitis, especially herpetic. - Withdrawal states, exogenous intoxications and post-nasal states (signs of other therapeutic, surgical and neurological diseases are absent or are observed by chance):
– Abstinence alcohol syndrome (delirium tremens), withdrawal of barbiturags, as well as other sedatives after their long-term use.
– Medicinal intoxications (phenamine, camphor, caffeine, ergot alkaloids, scopolamine, atropine, etc.).
– Post-seizure delirium.
Pathogenesis During Delirium
Delirium can be considered as a transient mental disorder, reflecting acute brain insufficiency, due to a diffuse metabolic disorder. Delirium is a kind of physiological decompensation of the brain functions, similar to the syndrome of heart, kidney or liver failure.
Delirium usually occurs due to disorders associated with various brain diseases and common diseases, and it can also occur under the influence of a number of chemicals, during hypoxia, sleep deprivation, and withdrawal symptoms during drug deprivation. Usually, among the causes of delirium are three main groups:
- diseases of the central nervous system (for example, epilepsy, meningitis, or encephalitis);
- systemic somatic diseases (for example, cardiac, pulmonary, renal or hepatic failure);
- intoxication (for example, neurotoxins with common infections, drugs, alcohol, medicines).
Symptoms of Delirium
Delirium can occur at the highest stage of an infectious disease. The delirium caused by alcohol is called delirium tremens. The duration of delirium can vary from several hours to several weeks. Although in general the memory of what has been experienced during delirium is usually preserved, there is often partial amnesia after delirium.
When delirium note the following somatovegetative disorders:
- sweating
- fluctuations in body temperature
- fluctuations in blood pressure
- muscle weakness
- tachycardia
- large spreading tremor
- shaky gait
The most complete clinical manifestations of delirium are described in patients with alcoholism. Symptoms usually develop within 2-3 days. The first manifestations of an impending attack are inability to concentrate, restless irritability, trembling, insomnia, and poor appetite. In approximately 30% of cases, the leading initial manifestations are one or more generalized seizures. The rest of the patient is disturbed by horrific dreams or hallucinations. There may be a short-term violation of adequate perception of the environment, which is revealed from random inappropriate comments.
The initial symptoms quickly give way to a comprehensive clinical picture, which in cases of severe illness is one of the most colorful and vibrant in medicine. The patient becomes inattentive and incapable of perceiving all the elements of the situation, the consciousness becomes darkened. He can talk continuously and randomly, looking tired and dazed, with an expression of concern and vague suspicion about danger on his face. In terms of speech content and behavior, it becomes obvious that the patient misunderstands the purpose of ordinary objects and surrounding sounds, that he has bright visual, auditory and tactile hallucinations, often unpleasant. At the outset, at the slightest contact with reality, patients can come to their senses and adequately answer questions, but almost immediately they fall back into a preoccupied darkened state, respond inappropriately, cannot think consistently and are not capable of self-orientation. Soon the patient can not for a moment get rid of hallucinations and does not recognize any relatives or doctor, can not sleep or sleep for short periods. There is a rough tremor and restlessness of movement. The face is red, the pupils are dilated, the sclera are injected, the pulse is frequent, and the body temperature may rise. There is excessive sweating, urine is excreted in small portions with high specific gravity. From other states of confusion, delirium is more clearly distinguished by increased activity of the vegetative nervous system.
In most patients, the symptoms of the disease disappear after 3-5 days, although some may occur within a few weeks. Most precisely at the end of the attack indicates a sound sleep of the patient or the appearance of periods of enlightenment in the mind, gradually increasing in duration. Recovery is usually complete. In a small percentage of cases of the most severe forms, death is possible.
Delirium can be very diverse not only in different patients, but also in the same person on different days or hours. In one patient, you can observe all the symptoms of the disease, in another – only some of the manifestations of this syndrome. With a mild course, as is the case with fever, delirium is characterized by the appearance of random wandering thoughts and incoherent utterances, interrupted by periods of enlightenment. This form of the disease with a lack of motor and autonomic hyperactivity is sometimes called calm (or hypokinetic) delirium and is considered the most difficult for differential diagnosis with other states of confusion. Excitement and excitement, reminiscent of delirium, can also occur with hepatic encephalopathy, hyponatremia, and temporarily with hypoglycemic conditions.
Diagnosis of Delirium
In the foreign literature, the possibility of using formalized clinical-nominal scales to measure the severity of delirium symptoms in dynamics in order to assess the effectiveness of therapeutic interventions and improve the diagnosis of this disorder is widely discussed. In everyday practice, the Confusion Assessment Method (CAM; Inouye et al., 1990), which takes into account the dynamics of the disorder, is popular for screening delirium. Also popular is the “Delirium Rating Scale-Revised-98” (Trzepacz PT et al., 1988; 1999) – a scale that allows you to quantitatively measure the severity of violations during delirium by 16 parameters (13 parameters – a subsidence scale of delirium, 3 parameters – a subscale, facilitating differential diagnosis of delirium). A more detailed study of the main neuropsychological functions is the Cognitive Test for Patients with Delirium (Cognitive Test for Delirium – CTD; Hart et al., 1996). This test, as well as the Revised Delirium Scale (DRS-R-98), allows their use even in cases where the patient’s ability to interact with the researcher is limited due to intubation, immobility, or lack of speech.
Treatment of Delirium
Treatment of delirium is primarily aimed at easing or eliminating the cause of this condition. It is important to meet the body’s need for fluids and nutrients. Medications are used to reduce anxiety and anxiety; it is also desirable that a close friend or relative is always with the patient. To prevent deception of view, the room should be well lit. The patient should be protected as much as possible from strangers, but if their appearance is absolutely necessary, detailed explanations are needed.