Delirium

Overview

Delirium is a serious change in mental abilities characterized by confused thinking and a lack of awareness of one's surroundings. It usually develops rapidly within hours or a few days and can be caused by various factors such as severe or long illnesses, imbalances in the body like low sodium, certain medications, infections, surgery, alcohol or drug use, or withdrawal. Delirium symptoms can be mistaken for dementia, and healthcare providers may consider input from family members or caregivers to diagnose the disorder. Symptoms can include reduced awareness of surroundings, poor thinking skills, and behavioral and emotional changes. There are three types of delirium identified by experts.

Understanding the disease

Symptoms

The symptoms of delirium usually begin over a few hours or a few days and tend to be worse at night when it's dark and things look less familiar. Primary symptoms include reduced awareness of surroundings, which may result in trouble focusing on a topic or changing topics, getting stuck on an idea rather than responding to questions, being easily distracted, and being withdrawn, with little or no activity or little response to surroundings. Poor thinking skills may also be present, appearing as poor memory, such as forgetting recent events, or not knowing where they are or who they are. Delirium can be caused by various factors, including a severe or long illness, an imbalance in the body, certain medicines, infection, surgery, alcohol or drug use or withdrawal, and more. There are three types of delirium: hyperactive, hypoactive, and mixed.

Risk Factors

The risk factors for developing delirium include any condition that results in a hospital stay, such as recovering from surgery or being in intensive care. Delirium is more common in older adults and in people who live in nursing homes. Other risk factors include brain disorders such as dementia, stroke, or Parkinson's disease; past delirium episodes; vision or hearing loss; multiple medical problems; an imbalance in the body, such as low sodium or low calcium; severe, long-lasting illness or an illness that will lead to death; fever and a new infection, particularly in children; exposure to a toxin; poor nutrition or a loss of too much body fluid; lack of sleep or severe emotional distress; pain; and surgery or another medical procedure that requires being put in a sleep-like state.

Development

Delirium can develop due to a variety of factors, including but not limited to:

1. An imbalance in the body, such as low sodium or low calcium
2. Severe, long-lasting illness or an illness that will lead to death
3. Fever and a new infection, particularly in children
4. Urinary tract infection, pneumonia, the flu or COVID-19, especially in older adults
5. Exposure to a toxin, such as carbon monoxide, cyanide, or other poisons
6. Poor nutrition or a loss of too much body fluid
7. Lack of sleep or severe emotional distress
8. Pain
9. Surgery or another medical procedure that requires being put in a sleep-like state
10. Certain medicines, including those that treat pain, sleep problems, mood disorders, allergies, asthma, swelling, Parkinson's disease, spasms or convulsions Delirium can manifest in different ways, with three types identified by experts:
11. Hyperactive delirium: Characterized by restlessness, pacing, rapid mood swings, and hallucinations.
12. Hypoactive delirium: Marked by inactivity, sluggishness, drowsiness, and disorientation.
13. Mixed delirium: A combination of hyperactive and hypoactive delirium symptoms, with the person quickly switching between restlessness and sluggishness. Risk factors for developing delirium include hospital stays, especially after surgery or intensive care, older adults, and people living in nursing homes. Other factors such as brain disorders, past delirium episodes, vision or hearing loss, and multiple medical problems can also increase the risk.

Assessment and Diagnosis

Triage

If you suspect delirium in a relative, friend, or someone in your care, it's important to consult with their healthcare provider. The doctor will rely on your input about the person's symptoms, typical thinking, and usual abilities to make a diagnosis. Early detection and intervention are crucial to addressing the underlying causes and preventing potential complications, such as an increased risk of death or the need for long-term care.

Diagnosis

A health care provider can diagnose delirium based on medical history and tests of mental status. The provider may ask about recent changes, infections, medications, or any new pain. They will also perform a mental status review, physical and neurological exams, and may order blood, urine, or other tests. Addressing any causes or triggers is the first goal of treatment, followed by supportive care to prevent complications. Before the appointment, it's helpful to make a list of the person's medications, care providers, and symptom details, as well as any questions for the health care provider.

Management and Treatment

Complications

Potential complications of delirium may include an imbalance in the body, such as low sodium or low calcium, severe or long-lasting illness, fever and a new infection, particularly in children, urinary tract infection, pneumonia, the flu or COVID-19, especially in older adults, exposure to a toxin, such as carbon monoxide, cyanide or other poisons, poor nutrition or a loss of too much body fluid, lack of sleep or severe emotional distress, pain, surgery or another medical procedure that requires being put in a sleep-like state, and some medicines taken alone or taken in combination that can trigger delirium. In severe or long-lasting cases, delirium may lead to a general decline in health, poor recovery from surgery, the need for long-term care, and an increased risk of death.

Prevention

delirium can be prevented or its severity can be reduced by addressing risk factors that might trigger an episode. In hospital settings, promoting good sleep habits, helping the person remain calm and well-oriented, and preventing medical problems or other complications can help prevent or reduce the severity of delirium. It's also important to avoid medicines used for sleep, such as diphenhydramine.

Treatment

Treating delirium involves addressing the underlying causes or triggers and creating a supportive environment for healing. Here are some steps to treat delirium:

1. Address the causes or triggers: The first goal of delirium treatment is to identify and address any underlying causes, such as stopping certain medications, treating infections, or addressing imbalances in the body.
2. Supportive care: This involves providing care to prevent complications. Key measures include protecting the airway, providing fluids and nutrition, assisting with movement, treating pain, addressing lack of bladder control, avoiding physical restraints and bladder tubes, and ensuring a stable and familiar environment.
3. Medications: Talk to the healthcare provider about medications that may trigger delirium symptoms. Some medications may need to be avoided or given at a lower dose. In certain cases, medications may be necessary to control pain or treat other symptoms. Antipsychotic medications may be considered if the person is agitated or experiencing hallucinations.
4. Encourage good sleep habits: Promoting good sleep habits, such as providing a calm, quiet setting, using appropriate lighting, maintaining a regular daytime schedule, encouraging self-care and activity during the day, and allowing for restful sleep at night can help improve the person's overall health and prevent further episodes of delirium.
5. Delirium prevention for relatives or caregivers: If you are a relative or caregiver of someone at risk of delirium, you can take steps to prevent episodes, such as promoting good sleep habits, maintaining a calm and oriented environment, and being aware of any potential triggers or causes. Remember, delirium treatment should be supervised and overseen by a healthcare provider.

Preparing for medical consultation