Delirium

Delirium: Description, Causes and Risk Factors:Alternative Names: Acute confusional state, acute brain syndrome.An altered state of consciousness, consisting of confusion, distractibility, disorientation, disordered thinking and memory, illusions, hallucinations, prominent hyperactivity, agitation and autonomic nervous system overactivity.Types  of delirium may include: Acute, alcohol withdrawal, anxious, delirium cordis, delirium tremens, posttraumatic, senile , and toxic.There are a large number of possible causes of delirium. Metabolic disorders are the single most common cause, accounting for 20-40% of all cases. This may result from organ failure, including liver or kidney failure. Other metabolic causes include diabetes mellitus, hyperthyroidism and hypothyroidism, vitamin deficiencies, and imbalances of fluids and electrolytes in the blood. Severe dehydration can also cause delirium.Underlying causes may include:Head trauma.
  • Fever.
  • Epilepsy.
  • Brain hemorrhage or infarction.
  • Brain tumor.
  • Low blood oxygen (hypoxemia).
  • High blood carbondioxide (hypercapnia).
  • Post-surgical complication.
Drug intoxication is also responsible for up to20% of delirium cases, either from side effects, overdose, or deliberate ingestion of a mind-altering substance. Medicinal drugs with delirium as a possible side effect or result of overdose include:Anticholinergics.
  • Sedatives.
  • Antidepressant drugs.
  • Anticonvulsant drugs.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs).
  • Corticosteroids.
  • Anticancer drugs.
Delirium may result from ingestion of legal or illegal psychoactive drugs, including:Marijuana.
  • LSD (lysergic acid diethylamide) and other hallucinogens.
  • Ethanol (drinking alcohol).
  • Amphetamines.
  • Cocaine.
  • Opiates, including heroin and morphine.
  • PCP (phencyclidine).
  • Inhalants.
Other causes may include:Heavy metals, such as lead, mercury, and arsenic.
  • Solvents, such as gasoline, kerosene, turpentine, benzene, and alcohols.
  • Carbon monoxide.
  • Refrigerants (Freon).
  • Insecticides, such as Parathion and Sevin.
  • Mushrooms, such as Amanita species.
  • Plants such as jimsonweed (Datura stramonium) and morning glory (Ipomoea spp.)
  • Animal venoms.
Risk Factors:Pre-existing dementia.
  • Severe medical illness.
  • Alcohol abuse.
  • Diminished ADL (activity of daily living).
  • Abnormal serum sodium.
  • Male gender.
  • Depression.
  • Hearing impairment.
  • Visual impairment.
  • Acute myocardial events.
  • Acute pulmonary events.
  • Fluid and electrolyte disturbance (including dehydration).
  • Drug withdrawal (sedatives, alcohol).
  • Infection (especially respiratory, urinary).
  • Medications (wide range, esp. psychoactive, anticholinergics and opioids).
  • Uncontrolled pain.
  • Urinary retention, faecal impaction.
  • Indwelling devices (urinary catheters).
  • Severe anemia.
  • Use of restraints.
  • Intracranial events (stroke, bleeding, infection).
Difference between delirium and dementia: Delirium is termed acute brain failure/disorder, dementia is termed chronic brain failure/disorder.Symptoms:delirium Symptoms may include:Changes in alertness.
  • Changes in feeling (sensation) and perception.
  • Changes in level of consciousness or awareness.
  • Changes in movement (may be inactive or slow moving).
  • Changes in sleep patterns, drowsiness.
  • Disorientation about time or place.
  • Unable to remember events.
  • Inability to think or behave with purpose.
  • Problems concentrating.
  • Incoherent speech (speech that doesn't make sense).
Emotional or personality changes may include:Anger. Diagnosis:Patients with delirium require a comprehensive evaluation of theircurrent and past medical conditions and treatments, includingmedications, with special attention paid to those conditions ortreatments that might be contributing to the delirium.Conduct a thorough assessment of the patient's symptoms,including all DSM-IV criteria (1. Due to a general medical condition, 2).Due to substanceintoxication, 3).Due to substance withdrawal, 4).Due to multiple etiologies, and 5). Nototherwise specified).
  • Distinguish among differential diagnostic possibilities; for patientswith features of delirium, the most common issue is determiningwhether the patient has dementia, delirium, or both.
  • Obtain information from medical records, psychiatric records,medical staff, family, and other sources.
Cognitive tests such as clock face, digit span, Trail Making tests may be needed.Basic laboratory tests may include:Blood chemistries: Electrolytes, glucose, calcium, albumin, BUN (blood urea nitrogen), creatinine, SGOT, SGPT, bilirubin, alkaline phosphatase, magnesium,phosphorus.
  • Complete blood count (CBC).
  • Blood tests (e.g., VDRL (Venereal Disease Research Laboratory test), heavy metal screen, B12 and folate levels, antinuclearantibody (ANA), urinary porphyrins, ammonia level, human immunodeficiency virus (HIV), erythrocyte sedimentation rate (ESR).
  • Arterial blood gases or oxygen saturation.
  • Urinalysis.
  • Urine culture and sensitivity (C&S).
  • Urine drug screen.
  • Blood cultures.
  • Serum levels of medications.
  • Cerebrospinal fluid (CSF) analysis.
Imaging tests may include:Electrocardiogram (ECG).
  • Chest X-ray.
  • Brain computerized tomography (CT) or magnetic resonance imaging (MRI).
  • Electroencephalogram (EEG).
Treatment:Treatment of delirium involves two main strategies.Treatment of the underlying presumed acute causes.
  • Optimizing conditions for the brain. This involves ensuring that the patient with delirium has adequate oxygenation, hydration, nutrition, and normal levels of metabolites, that drug effects are minimized, constipation treated, pain treated, and so on.
Detection and management of mental stress is also very important. Thus, the traditional concept that the treatment of delirium is 'treat the cause' is not adequate; patients with delirium actually require a highly detailed and expert analysis of all the factors which might be disrupting brain function.Pharmacological treatment for delirium depends on its cause:Avoid use of sedative or hypnotic medications except for the treatment of alcohol or sedative withdrawal.
  • Antipsychotic medication in low doses might sometimes be needed to control agitation, psychotic symptoms or aggression. Beware of drug side-effects and drug interactions. Antipsychotics, preferably those with minimal anticholinergic activity, such as haloperidol or risperidone may be preferred.
  • When drugs are required because of severe behavioural disturbance or risk to self and/or others, low-dose risperidone is the usual drug of first choice, except in alcohol or drug withdrawal states or in patients with liver disease in might be helpful.
Other treatments that may be helpful include behavior modification to control unacceptable or dangerous behaviors.Disclaimer: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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