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Delirium
Delirium is a syndrome
of cerebral metabolism or alteration in levels of neurotransmitters
associated with cognitive, behavioral and affective disturbances.
According to the DSM-IV, the essential feature of delirium is
“a disturbance of consciousness that is accompanied by a change in
cognition that cannot be better accounted for by a preexisting or
evolving dementia”. Delirium
is common in elderly patients with acute or chronic illnesses and is
often under-recognized in clinical settings. It has been estimated that approximately 50% of patients
suffering from delirium have been misdiagnosed. In younger patients, delirium is often misdiagnosed as
schizophrenia; in older patients, delirium is often misdiagnosed as
dementia.
The following symptoms
are likely to indicate delirium rather than uncomplicated dementia:
·
Sudden
onset of cognitive impairment
·
Disorientation
·
Disturbances
in attention
·
Decline
in level of consciousness
·
Perceptual
disturbances (e.g. hallucinations)
Other symptoms of
delirium include: delusions,
fluctuations in mood, ranging from euphoria to fear, impaired
ability to focus, high or low levels of activity (drowsy to hyper
alert), and disturbances in sleep/ wake cycle.
Attention is generally impaired, with wandering of attention,
perseveration, and distractibility.
The disturbance tends to fluctuate during the course of the
day, with “sundowning” a common feature.
The duration of delirium can range from a few days to weeks,
particularly in individuals with a coexisting dementia.
The following types of
medications are common causes of delirium:
·
Anticholinergic
agents
·
Antipsychotic
agents
·
Digoxin
·
H2
blocking agents
·
Antihypertensive
agents
Other common causes of
delirium include:
·
Surgery
in anyone over age 60
·
Fractures
·
Infections
·
Relocations
·
Nutritional
deficits- Vitamin K (potassium) deficiency
·
Electrolyte
imbalance
·
Illness
Elderly persons who
develop delirium from the gradual accumulation of long-acting
benzodiazepines may present with an insidious onset and gradual
progression of cognitive impairment that may mimic AD.
Urinary tract infections have been found to be the underlying
cause of delirium in 25% of cases.
Another possible cause is dehydration and electrolyte
imbalance secondary to under-hydration.
Clinical Features of
Delirium (Caine & Grossman, 1992)
| Arousal
|
Psychomotor Activity
|
Personality
|
| Waxing-waning
|
Restlessness |
Apathy |
| Nighttime
confusion |
Somnolence |
Irritability |
|
("sundowning") |
Agitation |
Disinhibition |
| Drowsy |
Posturing |
Bizarre
behavior |
| Vigilant |
Reversal
of sleep-wake cycle |
|
| Stuper
& coma when severe |
|
|
| |
|
|
| Abnormal
beliefs |
Cognitive |
Neurological |
| Suspiciousness |
Perplexity |
Tremor |
| Paranoia |
Disorientation |
Nystagmus |
| Misperceptions |
Distractibility |
Asterixis |
| Illusions |
Perseveration |
Myoclonus |
| Hallucinations |
Poor
memory |
Hyperactive
reflexes |
| |
|
|
| Mood |
EEG |
|
| Lability |
Mild
delirium: Mild slowing; low voltage |
| Depression |
Severe
delirium; Diffuse severe slowing; progressive disorganization |
| Euphoria |
|
|
| |
|
|
It
is essential that the clinician identify delirium since delirium is
a medical emergency requiring further medical evaluation and
treatment. Ideally,
treatment should be directed toward the underlying disorder.
Frequently, however, the underlying disorder is either not
discernible or not completely correctable and symptomatic treatment
becomes necessary if agitation, anxiety, delusions, allocations, or
other behavioral symptoms interfere with patient management or
threaten the safety of others in the environment. Ins such cases, low doses of neuroleptics may be helpful;
however neuroleptics may produce hypotension, lower seizure
threshold, and contribute to increased number of falls in the
fragile, elderly delirious patient.
Management
of Combative Behavior
¨
Clear
the area – the fewer people around (staff and other residents),
the better
¨
Stay
calm – keep voice tone gentle, calm
¨
Respect
the resident’s personal space – keep your distance
¨
Reduce
environmental stimulation – take resident to a quiet location
where there is a minimum of activity
¨
Offer
reassurance
¨
Don’t
argue with the resident
¨
Avoid
asking questions that require memory
¨
Keep
instructions brief
¨
Redirect
to new activity
¨
Use
distraction
Psychiatric
Problems and Patient Satisfaction with Health Care
In
a study supported in part by the Agency for Health Care Policy and
Research researchers from Harvard Medical School1
examined the relationship between psychiatric disorders and care
satisfaction in a national sample of elderly and disabled patients.
Psychiatric disorders ranged from affective, anxiety, and psychotic
disorders to organic, substance abuse, and/or personality disorders.
Findings indicate that aged and disabled Medicare beneficiaries with
psychiatric disorders are significantly less likely than those
without disorders to be satisfied with the overall quality of their
health care. This group is particularly apt to be dissatisfied with
follow-up care and physicians' concern for their overall health.
1Hermann,
R.C., Ettner, S.L., and Dowart, R.A.
The influence of psychiatric disorders on patients' ratings
of satisfaction with health care. Medical Care 36(5), pp.
720-727, 1998.
Treating
Post-stroke Depression Aids Cognitive Recovery
Following
a stroke, about 40% of patients show signs of depression.
About half of these patients have major depression and half
have minor depression. For
patients with frontal lobe damage, about 75-80% will develop
depression. A recent study at the University of Iowa, stroke patients who
exhibited either major or minor depression received either
antidepressant medication (nortriptyline) or placebo.
Comparisons of performance on the Mini-Mental State
Examination showed greater improvement for patients who received
nortriptyline compared with those who received the placebo.
The researcher concluded that, “…you can significantly
improve the degree of recovery by recognizing and treating the
depressive disorder.” These
findings underline the importance of identification and treatment of
depression in stroke patients.
Robinson,
R.G. Stroke,
31:1482-1486. In Reuters
Health Information
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Events
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Welcome
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Feb.
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