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Delirium is an acute and relatively sudden (developing over hours to days) decline in attention-focus, perception, and cognition. In medical usage it is not synonymous with drowsiness, and may occur without it. Delirium is not the same as dementia (the two entities have different diagnostic criteria), though it commonly occurs in demented patients.


Delirium may be of a hyperactive variety manifested by 'positive' symptoms of agitation or combativeness, or it may be of a hypoactive variety (often referred to as 'quiet' delirium) manifested by 'negative' symptoms such as inability to converse or focus attention or follow commands. 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. Delirium is commonly associated with a disturbance of consciousness (e.g., reduced clarity of awareness of the environment). The change in cognition (memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance, must be one that is not better accounted for by a pre-existing, established, or evolving dementia. Usually the rapidly fluctuating time course of delirium is used to help in the latter distinction.[1]

 
Delirium itself is not a disease, but rather a clinical syndrome (a set of symptoms), which result from an underlying disease or new problem with mentation. Like its components (inability to focus attention, confusion and various impairments in awareness and temporal and spatial orientation), delirium is simply the common symptomatic manifestation of early brain or mental dysfunction (for any reason).
Without careful assessment, delirium can easily be confused with a number of psychiatric disorders because many of the signs and symptoms are conditions present in dementia, depression, and psychosis. Delirium is probably the single most common acute disorder affecting adults in general hospitals. It affects 10-20% of all hospitalized adults, and 30-40% of elderly hospitalized patients and up to 80% of ICU patients. Treatment of delirium requires treatment of the underlying causes. In some cases, temporary or palliative or symptomatic treatments are used to comfort patients or to allow better patient management (for example, a patient who, without understanding, is trying to pull out a ventilation tube that is required for survival).


Educational information is available for medical and non-medical persons with videos, management protocols, links to references, lectures, recent evidence from studies, implementation packets for hospitals, and even comments to families and loved ones for those witnessing someone going through a delirious episode.

In common usage, delirium is often used to refer to drowsiness, disorientation, and hallucination. In broader medical terminology, however, a number of other symptoms, including a sudden inability to focus attention, and even (occasionally) sleeplessness and severe agitation and irritability, also define "delirium," and hallucination, drowsiness, and disorientation are not required.

Diagnosis:

Differential points from other processes and syndromes that cause cognitive dysfunction:

  • Delirium may be distinguished from psychosis, in which consciousness and cognition may not be impaired (however, there may be overlap, as some acute psychosis, especially with mania, is capable of producing delirium-like states).
  • Delirium is distinguished from dementia (chronic organic brain syndrome) which describes an "acquired" (non-congenital) and usually irreversible cognitive and psychosocial decline in function. Dementia usually results from an identifiable degenerative brain disease (for example Alzheimer disease or Huntington's disease). Dementia is usually not associated with a change in level of consciousness, and a diagnosis of dementia requires a chronic impairment.

  • Delirium is distinguished from depression.

  • Delirium is distinguished by time-course from the confusion and lack of attention which result from long term learning disorders and varieties of congenital brain dysfunction. Delirium has also been referred to as 'acute confusional state' or 'acute brain syndrome'. The key word in both of these descriptions is "acute" (meaning: of recent onset), since delirium may share many of the clinical (i.e., symptomatic) features of dementia, developmental disability, or attention-deficit hyperactivity disorder, with the important exception of symptom duration.

  • Delirium is not the same as confusion, although the two syndromes may overlap and be present at the same time. However, a confused patient may not be delirious (an example would be a stable, demented person who is disoriented to time and place), and a delirious person may not be confused (for example. a person in severe pain may not be able to focus attention, but may be completely oriented and not at all confused).

It is a corollary of the above differential criteria that a diagnosis of delirium cannot be made without a previous assessment or knowledge of the affected person's baseline level of cognitive function. Several valid and reliable rating scales now exist which can be used to accurately diagnose delirium.

Causes
Delirium, like mental confusion, is a very general and nonspecific symptom of organ dysfunction, where the organ in question is the brain. In addition to many organic causes relating to a structural defect or a metabolic problem in the brain (analogous to hardware problems in a computer), there are also some psychiatric causes, which may also include a component of mental or emotional stress, mental disease, or other "programming" problems (analogous to software problems in a computer).

Delirium may be caused by severe physical illness, or any process which interferes with the normal metabolism or function of the brain. For example, fever, pain, poisons (including toxic drug reactions), brain injury, surgery, traumatic shock, severe lack of food or water or sleep, and even withdrawal symptoms of certain drug and alcohol dependent states, are all known to cause delirium.

In addition, there is an interaction between acute and chronic symptoms of brain dysfunction; delirious states are more easily produced in people already suffering with underlying chronic brain dysfunction.

A very common cause of delirium in elderly people is a urinary tract infection, which is easily treatable with antibiotics, reversing the delirium.

Too many to list by specific pathology, major categories of the cause of delirium include:
Critical illness | The most common behavioral manifestation of acute brain dysfunction is delirium, which occurs in up to 60% to 80% of mechanically ventilated medical and surgical ICU patients and 50% to 70% of non-ventilated medical ICU patients. During the ICU stay, acute delirium is associated with complications of mechanical ventilation including nosocomial pneumonia, self-extubation, and reintubation. ICU delirium predicts a 3- to 11-fold increased risk of death at 6 months even after controlling for relevant covariates such as severity of illness. Of late, delirium has been recognized by some as a sixth vital sign, and it is recommended that delirium assessment be a part of routine ICU management. The elderly may be at particular risk for this spectrum of delirium and dementia. A firm understanding of the pathophysiologic mechanisms of delirium remains elusive despite improved diagnosis and potential treatments. Delirium on Vanderbuilt Website


Substance withdrawal |  Drug withdrawal is a common cause of delirium. The most notable are alcohol withdrawal and benzodiazepine withdrawal but other drug withdrawals both from licit and illicit drugs can sometimes cause delirium.

Gross structural brain disorders
• Head trauma (i.e., concussion, traumatic bleeding, penetrating injury, etc.)
• Gross structural damage from brain disease (stroke, spontaneous bleeding, tumor, etc.)

Neurological disorders
• Various neurological disorders
• Lack of sleep

Circulatory
• Intracranial Hypertension

Lack of essential metabolic fuels, nutrients, etc.
• Hypoxia,
• Hypoglycemia
• Electrolyte imbalance (dehydration, water intoxication)

Toxication
• Intoxication various drugs, alcohol, anesthetics
• Sudden withdrawal of chronic drug use ("de-tox") in a person with certain types of drug addiction (e.g. alcohol, see delirium tremens, and many other sedating drugs)
• Poisons (including carbon monoxide and metabolic blockade)
• Medications including psychotropic medications

Mental illness per se is not a cause, as a matter of definition
Some mental illnesses, such as mania, or some types of acute psychosis, may cause a rapidly fluctuating impairment of cognitive function and ability to focus. However, they are not technically causes of delirium, since any fluctuating cognitive symptoms that occur as a result of these mental disorders are considered by definition to be due to the mental disorder itself, and to be a part of it. Thus, physical disorders can be said to produce delirium as a mental side-effect or symptom; however primary mental disorders which produce the symptom cannot be put into this category, once identified. However, such symptoms may be impossible to distinguish clinically from delirium resulting from physical disorders, if a diagnosis of an underlying mental disorder has yet to be made.

Few of Important medicines.


APIS MELLIFICA :
Stupor with murmuring delirium
Dread of death .
Fear of being poisoning.

ARNICA MONTANA :
Stupor, sits as if in thought, yet things of nothing like a waking dream.
Trembling of lower lips.
Decline to answer questions.

BELLADONNA :
Violent delirium with attempts to run away.
To strike bite and spit upon people.
Congestion to brain with great drowsiness, but inability to sleep.
Delirium with fear of imaginary things

BRYONIA :
Nocturnal delirium about business.
Visions when shutting eyes.
Irritability and hasty speech.

CAMPHORA :
Delirious somnolent with slow fever at night.
Dullness and heat of head with cold clammy skin.

CAPSICUM :
Coma and delirium awakens with fright.
Screams and remains full of fears.

CUPRUM MET :
Delirium hollowing and muttering, and afraid of every one who approaches him.
Shrinking away from them,tries to escape.
Restless and anguish and tossing about.

GELSEMIUM :
Delirium in sleep of waking with incoherent talk.
Delirium as soon as he falls asleep.
Loquacity, brilliant eyes with shooting through temples and nose.

HYOSCYAMUS :
When spoken to he answers correctly. But unconsciousness and delirium immediately return. Delirium continious while awake.
Complaints of imaginary things indistinct and muttering loquacity.
Insane passion for work. Desire to uncover, aversion to light.

LACHESIS :
Delirium fears she will be dammed, delirium at night. Muttering at drowsy red face, slow difficult speech and dropped jaw. Delirium with great loquacity, constantly jumping from subject to subject. Delirium from over watching.

LYCOPODIUM :
Sopor, delirium, uses wrong words for correct ideas.

NUX MOSCHATA :
Delirium, violent vertigo, strange gestures, loud, improper talk, sleeplessness, laugher, everything appear ludicrous talks loudly to himself.

OPIUM :
Mild or furibund delirium, with loud talking, laughing, attempts to escape.
Venous congestion with dark-red face, imagines parts of body very large, things she is not at home.

PHOSPHORIC ACID :
Quiet delirium with great stupefaction and dullness of head, unintelligible muttering delirium.

PHOSPHORUS :
Ecstacy, notion that his body is all in pieces and he cannot get in together, mania de grandeur in his delirium.
Erotismus and sexual excitement and seeks to gratify his lust.

PLUMBUM :
Deliria alternating with lead colic, patient bites and strikes, though his hands tremble as well as his head and yellow mucous collects about mouth and teeth.

PODOPHYLLUM :
Delirious loquacity during fever heat.

RHUSTOX :
Delirium, talks incoherently to himself, mental operations slow and difficult, answers correctly but slowly, sometimes hastly.
Low mild delirium, thinks he is roaming over fields or hard at work.

STRAMONIUM :
Loquacious delirium, singing, laughing, whistling, constant involuntary odd motions of limbs and body.
All objects appear oblique, delirium with graceful gesticulations, patient conscious of her mentally unnatural condition.

VERATRUM ALBUM :
Delirium, heavy, soporous sleep, restless, anxious, frightened and imaginary things, lascivious and lewd in talk and deed, thirsty, cramps in legs.
Cold sweat, tingling, irregular pulse.

ZINCUM :
Delirium with attemps to get out of bed, staring eyes, constant trembling of the hands and coldness of the extremities.


 

 


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