For other forms of cognitive impairment, see Cognitive impairment. Delirium, or acute confusional state, is an organically caused decline from a previously attained baseline level of cognitive function. It is typified by fluctuating course, attentional deficits and generalized severe disorganization of behavior. It typically involves other cognitive deficits, changes in arousal (hyperactive, hypoactive, or mixed), perceptual deficits, altered sleep- wake cycle, and psychotic features such as hallucinations and delusions. Delirium itself is not a disease, but rather a clinical syndrome (a set of symptoms). It may result from an underlying disease, over- consumption of alcohol, from drugs administered during treatment of a disease, withdrawal from drugs or from any number of health factors. Delirium may be difficult to diagnose without the proper establishment of the baseline mental function of a patient.
Delirium may be caused by a disease process outside the brain that nonetheless affects the brain, such as infection (urinary tract infection, pneumonia) or drug effects, particularly anticholinergics or other CNS depressants (benzodiazepines and opioids). Like its components (inability to focus attention, mental confusion and various impairments in awareness and temporal and spatial orientation), delirium is the common manifestation of new organic brain dysfunction (for any reason). Delirium requires both a sudden change in mentation, and an organic cause for this. Thus, without careful assessment and history, delirium can easily be confused with a number of psychiatric disorders or long term organic brain syndromes, because many of the signs and symptoms of delirium are conditions also present in dementia, depression, and psychosis.
In some cases, temporary or palliative or symptomatic treatments are used to comfort the person or to allow other care (for example, a person who, without understanding, is trying to pull out a ventilation tube that is required for survival). Delirium is probably the single most common acute disorder affecting adults in general hospitals. It affects 1. 0- 2. ICU. Among those requiring critical care, delirium is a risk for death within the next year. In medical terminology, however, a number of different symptoms, including temporary disturbance in consciousness, with reduced ability to focus attention and solve problems, are the core features of delirium. Occasionally sleeplessness and severe agitation and irritability are part of .
However, all include some core features. The core features are: Disturbance of consciousness (that is, reduced clarity of awareness of the environment, with reduced ability to focus, sustain, or shift attention).
During the 2. 0th century, delirium was described as a . Lipowski described delirium as a disorder of attention, wakefulness, cognition, and motor behaviour, while a disturbance in attention is often considered the cardinal symptom. In its hyperactive form, it is manifested as severe confusion and disorientation, developing with relatively rapid onset and fluctuating in intensity. In its hypoactive form, it is manifested by an equally sudden withdrawal from interaction with the outside world. Delirium may occur in a mixed type where someone may fluctuate between both hyper- and hypoactive periods. Delirium as a syndrome is one which occurs more frequently in people in their later years.
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However, when it occurs in the course of a critical illness, delirium has been found to occur in young and old patients at relatively even rates. Inattention and associated cognitive deficits. Disorientation (another symptom of confusion, and usually a more severe one) describes the loss of awareness of the surroundings, environment and context in which the person exists. It may also appear with delirium, but it is not required, as noted. Disorientation may occur in time (not knowing what time of day, day of week, month, season or year it is), place (not knowing where one is) or person (not knowing who one is). Memory impairment occurs.
Reduction in formation of new long- term memory (which by definition survives withdrawal of attention), is common in delirium, because initial formation of (new) long- term memories generally requires an even higher degree of attention than do short- term memory tasks. Since older memories are retained without need of concentration, previously formed long- term memories (i.
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Higher level thinking. Though none of these cognitive deficits is specific to delirium, the array and pattern is highly suggestive. Language disturbances in delirium include anomic aphasia, paraphasias, impaired comprehension, agraphia, and word- finding difficulties. Incoherent or illogical / rambling conversation is reported commonly. Disorganised thinking includes tangentiality, circumstantiality and a proneness to loose associations between elements of thought which results in speech that often makes limited sense with multiple apparent irrelevancies.
This aspect of delirium is common but often difficult for non- experts to assess reliably. Sleep changes. Minor disturbances with insomnia or excessive daytime somnolence may be hard to distinguish from other medically ill patients without delirium, but delirium typically involves more substantial alterations with sleep fragmentation or even complete sleep- wake cycle reversal that reflect disturbed circadian rhythm regulation. The relationship of circadian disturbances to the characteristic fluctuating severity of delirium symptoms over a 2.
Motor activity alterations are very common in delirium. They have been used to define clinical subtypes (hypoactive, hyperactive, mixed) though studies are inconsistent as to the prevalence of these subtypes.
Psychotic symptoms occur in both although the prevailing stereotype suggests that they only occur in hyperactive cases. Hypoactive cases are prone to non detection or misdiagnosis as depression. A range of studies suggest that motor subtypes differ regarding underlying pathophysiology, treatment needs, and prognosis for function and mortality though inconsistent subtype definitions and poorer detection of hypoactives impacts interpretation of these findings. While the common non- medical view of a delirious patient is one who is hallucinating, most people who are medically delirious do not have either hallucinations or delusions. Thought content abnormalities include suspiciousness, overvalued ideation and frank delusions. Delusions are typically poorly formed and less stereotyped than in schizophrenia or Alzheimer. They usually relate to persecutory themes of impending danger or threat in the immediate environment (e.
Misperceptions include depersonalisation, delusional misidentifications, illusions and hallucinations. Hallucinations and illusions are frequently visual though can be tactile and auditory. Abnormalities of affect which may attend the state of delirium may include many distortions to perceived or communicated emotional states. Emotional states may also fluctuate, so that a delirious person may rapidly change between, for example, terror, sadness and jocularity. Interestingly, Barrough noted in 1.
Another way of looking at dementia, however, is not strictly based on the decline component but on the degree of memory and executive function problems. It is now known, for example, that between 5. ICU patients have tremendous problems with ongoing brain dysfunction that looks a lot like the degree of problems experienced by Alzheimer.
The implications of such an . The societal relevance is also huge when one considers work- force issues related to the inability of a young wage earner being unable to work because of either being a newly disabled ICU survivor themselves or because they now have to care for their family member who is now suffering this . A predisposing factor might be any biological, psychological or social factor that increases an individual.
An individual with multiple predisposing factors is said to have . A precipitating factor is any biological, psychological or social factor that can trigger delirium. The division of causes into . Frailty is usually the result of multiple physical and social causes, and is often viewed as a symptom of old age or ill health.
Health can be described as a balance between fitness and frailty, in which fitness results from physical and socioeconomic assets, and frailty results from physical and socioeconomic deficits. Frail individuals (i.
In a frail individual, a single or mild precipitating factor could be sufficient to trigger an episode of delirium. Conversely, delirium may only result in a fit individual if they suffer serious or multiple precipitating factors.
It is important to note that the factors affecting the fitness or frailty of an individual can change over time, thus an individual. Clinical environments can also precipitate delirium, and optimal nursing and medical care is a key component of delirium prevention. Earliest rodent models of delirium used an antagonist of the muscarinic acetylcholine receptors, atropine, to induce cognitive and EEG changes similar to delirium.
Similar anticholinergic drugs such as biperiden and scopolamine have also produced delirium- like effects. These models, along with clinical studies of drugs with .
Modeling this in mice also causes robust brain dysfunction and probably a delirium- like state, although these animals are typically too sick to assess cognitively and measures such as EEG and magnetic resonance imaging/spectroscopy are necessary to demonstrate dysfunction. Animal models that interrogate interactions between prior degenerative pathology and superimposed systemic inflammation have been developed more recently and these demonstrate that even mild systemic inflammation, a frequent trigger for clinical delirium, induces acute and transient attentional/working memory deficits, but only in animals with prior pathology.