Delirium - Wikipedia

Delirium (also known as acute confusional state) is an organically caused decline from a previous baseline mental functioning, that develops over a short period ... Delirium FromWikipedia,thefreeencyclopedia Jumptonavigation Jumptosearch Thisarticleisaboutthementalstateandmedicalcondition.Forotheruses,seeDelirium(disambiguation). Severeconfusionthatdevelopsquickly,andoftenfluctuatesinintensity MedicalconditionDeliriumOthernamesAcuteconfusionalstateSpecialtyPsychiatry,Geriatrics,Intensivecaremedicine,NeurologySymptomsagitation,confusion,drowsiness,hallucinations,delusions,memoryproblemsUsualonsetAnyage,butmoreofteninpeople65ormoreyearsofageDurationdaystoweeks,sometimesmonthsTypesHyperactive,Hypoactive,MixedstateCausesNotwellunderstoodRiskfactorsInfection,chronichealthproblems,certainmedications,neurologicalproblems,sleepdeprivation,surgeryDifferentialdiagnosisDementiaTreatmentMedication,treatingunderlyingcauseMedicationHaloperidol,Risperidone,Olanzapine,Quetiapine Delirium(alsoknownasacuteconfusionalstate)isanorganicallycauseddeclinefromapreviousbaselinementalfunctioning,thatdevelopsoverashortperiodoftime,typicallyhourstodays.[1][2]Deliriumisasyndromeencompassingdisturbancesinattention,consciousness,andcognition.Itmayalsoinvolveotherneurologicaldeficits,suchaspsychomotordisturbances(e.g.hyperactive,hypoactive,ormixed),impairedsleep-wakecycle,emotionaldisturbances,andperceptualdisturbances(e.g.hallucinationsanddelusions),althoughthesefeaturesarenotrequiredfordiagnosis. Deliriumiscausedbyanacuteorganicprocess,whichisaphysicallyidentifiablestructural,functional,orchemicalprobleminthebrainthatmayarisefromadiseaseprocessoutsidethebrainthatnonethelessaffectsthebrain.Itmayresultfromanunderlyingdiseaseprocess(e.g.infection,hypoxia),sideeffectofamedication,withdrawalfromdrugs,over-consumptionofalcohol,usageofhallucinogenicdeliriants,orfromanynumberoffactorsaffectingone'soverallhealth(e.g.malnutrition,pain,etc.).Incontrast,fluctuationsinmentalstatus/functionduetochangesinprimarilypsychiatricprocessesordiseases(e.g.schizophrenia,bipolardisorder)donot,bydefinition,meetthecriteriafor'delirium.'[1] Deliriummaybedifficulttodiagnosewithouttheproperestablishmentofaperson'susualmentalfunction.Withoutcarefulassessmentandhistory,deliriumcaneasilybeconfusedwithanumberofpsychiatricdisordersorchronicorganicbrainsyndromesbecauseofmanyoverlappingsignsandsymptomsincommonwithdementia,depression,psychosis,etc.[3]Deliriummaymanifestfromabaselineofexistingmentalillness,baselineintellectualdisability,ordementia,withoutbeingduetoanyoftheseproblems. Treatmentofdeliriumrequiresidentifyingandmanagingtheunderlyingcauses,managingdeliriumsymptoms,andreducingtheriskofcomplications.[4]Insomecases,temporaryorsymptomatictreatmentsareusedtocomfortthepersonortofacilitateothercare(e.g.preventingpeoplefrompullingoutabreathingtube).Antipsychoticsarenotsupportedforthetreatmentorpreventionofdeliriumamongthosewhoareinhospital;howevertheywillbeusedincaseswhereapatienthasahistoryofanxiety,hallucinationsoriftheyareadangertothemselvesorothers.[5][6][7][8][9]Whendeliriumiscausedbyalcoholorsedativehypnoticwithdrawal,benzodiazepinesaretypicallyusedasatreatment.[10]Thereisevidencethattheriskofdeliriuminhospitalizedpeoplecanbereducedbysystematicgoodgeneralcare.[11]InaDSMassessment,deliriumwasfoundtoaffect14–24%ofallhospitalizedindividuals,withanoverallprevalenceforthegeneralpopulationas1–2%,increasingwithage,reaching14%ofadultsoverage85.Amongolderadults,deliriumwasfoundtooccurin15–53%ofthosepost-surgery,70–87%ofthoseintheICU,andinupto60%ofthoseinnursinghomesorpost-acutecaresettings.[2]Amongthoserequiringcriticalcare,deliriumisariskfordeathwithinthenextyear.[12] Contents 1Definition 2Signsandsymptoms 3Causes 3.1Predisposingfactors 3.2Precipitatingfactors 4Pathophysiology 4.1Animalmodels 4.2Cerebrospinalfluid 4.3Neuroimaging 4.4Neurophysiology 4.5Neuropathology 5Diagnosis 5.1Generalsetting 5.2Intensivecareunit 5.3Differentialdiagnosis 6Prevention 7Treatment 7.1Multidomaininterventions 7.2Medications 8Prognosis 8.1DementiainICUsurvivors 9Epidemiology 10Societyandculture 10.1Costs 11References 12Furtherreading 13Externallinks Definition[edit] Incommonusage,deliriumisoftenusedtorefertodrowsiness,disorientation,andhallucination.Inmedicalterminology,however,acutedisturbanceinconsciousness/attentionandanumberofdifferentcognitivesymptomsarethecorefeaturesofdelirium. Severalmedicaldefinitionsofdeliriumexist(includingthoseintheDSMandICD-10),[2][13]butthecorefeaturesremainthesame.In2013,theAmericanPsychiatricAssociationreleasedthefiftheditionoftheDSM(DSM-5)withthefollowingcriteriafordiagnosis:[2] A.Disturbanceinattentionandawareness.Thisisarequiredsymptomandinvolveseasydistraction,inabilitytomaintainattentionalfocus,andvaryinglevelsofalertness.[14] B.Onsetisacute(fromhourstodays),representingachangefrombaselinementationwithfluctuationsthroughouttheday C.Atleastoneadditionalcognitivedisturbance(inmemory,orientation,language,visuospatialability,orperception) D.Thedisturbances(criteriaAandC)arenotbetterexplainedbyanotherneurocognitivedisorder E.Thereisevidencethatthedisturbancesabovearea"directphysiologicalconsequence"ofanothermedicalcondition,substanceintoxicationorwithdrawal,toxin,orvariouscombinationsofcauses Signsandsymptoms[edit] Deliriumexistsasastageofconsciousnesssomewhereinthespectrumbetweennormalawakeness/alertnessandcoma.Whilerequiringanacutedisturbanceinconsciousness/attentionandcognition,deliriumisasyndromeencompassinganarrayofneuropsychiatricsymptoms.[14] Therangeofclinicalfeaturesinclude:poorattention/vigilance(100%),memoryimpairment(64–100%),cloudingofconsciousness(45–100%),disorientation(43–100%),acuteonset(93%),disorganizedthinking/thoughtdisorder(59–95%),diffusecognitiveimpairment(77%),languagedisorder(41–93%),sleepdisturbance(25–96%),moodlability(43–63%),psychomotorchanges(e.g.hyperactive,hypoactive,mixed)(38–55%),delusions(18–68%),andperceptualchange/hallucinations(17–55%).[14]Thesevariousfeaturesofdeliriumarefurtherdescribedbelow: Inattention:Asarequiredsymptomtodiagnosedelirium,thisischaracterizedbydistractibilityandaninabilitytoshiftand/orsustainattention.[2] Memoryimpairment:Memoryimpairmentislinkedtoinattention,especiallyreducedformationofnewlong-termmemorywherehigherdegreesofattentionismorenecessarythanforshort-termmemory.Sinceoldermemoriesareretainedwithoutneedofconcentration,previouslyformedlong-termmemories(i.e.thoseformedbeforetheonsetofdelirium)areusuallypreservedinallbutthemostseverecasesofdelirium. Disorientation:Asanothersymptomofconfusion,andusuallyamoresevereone,thisdescribesthelossofawarenessofthesurroundings,environmentandcontextinwhichthepersonexists.Onemaybedisorientedtotime,place,orself. Disorganizedthinking:Disorganizedthinkingisusuallynoticedwithspeechthatmakeslimitedsensewithapparentirrelevancies,andcaninvolvepovertyofspeech,looseassociations,perseveration,tangentiality,andothersignsofaformalthoughtdisorder. Languagedisturbances:Anomicaphasia,paraphasia,impairedcomprehension,agraphia,andword-findingdifficultiesallinvolveimpairmentoflinguisticinformationprocessing. Sleepchanges:Sleepdisturbancesindeliriumreflectdisturbedcircadianrhythmregulation,typicallyinvolvingfragmentedsleeporevensleep-wakecyclereversal(i.e.activeatnight,sleepingduringtheday)andoftenprecedingtheonsetofadeliriumepisode Psychoticsymptoms:Symptomsofpsychosisincludesuspiciousness,overvaluedideationandfrankdelusions.DelusionsaretypicallypoorlyformedandlessstereotypedthaninschizophreniaorAlzheimer'sdisease.Theyusuallyrelatetopersecutorythemesofimpendingdangerorthreatintheimmediateenvironment(e.g.beingpoisonedbynurses). Moodlability:Distortionstoperceivedorcommunicatedemotionalstatesaswellasfluctuatingemotionalstatescanmanifestinadeliriousperson(e.g.rapidchangesbetweenterror,sadnessandjoking).[15] Motoractivitychanges:Deliriumhasbeencommonlyclassifiedintopsychomotorsubtypesofhypoactive,hyperactive,andmixed,[16]thoughstudiesareinconsistentastotheprevalenceofthesesubtypes.[17]Hypoactivecasesarepronetonon-detectionormisdiagnosisasdepression.Arangeofstudiessuggestthatmotorsubtypesdifferregardingunderlyingpathophysiology,treatmentneeds,andprognosisforfunctionandmortalitythoughinconsistentsubtypedefinitionsandpoorerdetectionofhypoactivesubtypesimpactsinterpretationofthesefindings.[18]LiptzinandLevkofffirstdescribedthesesubtypesin1992[14]asfollowing: Hyperactivesymptomsincludehyper-vigilance,restlessness,fastorloudspeech,irritability,combativeness,impatience,swearing,singing,laughing,uncooperativeness,euphoria,anger,wandering,easystartling,fastmotorresponses,distractibility,tangentiality,nightmares,andpersistentthoughts(hyperactivesub-typingisdefinedwithatleastthreeoftheabove).[19] Hypoactivesymptomsincludeunawareness,decreasedalertness,sparseorslowspeech,lethargy,slowedmovements,staring,andapathy(hypoactivesub-typingisdefinedwithatleastfouroftheabove).[19] Causes[edit] Deliriumarisesthroughtheinteractionofanumberofpredisposingandprecipitatingfactors.[20] Individualswithmultipleand/orsignificantpredisposingfactorsarehighlyatriskforsufferinganepisodeofdeliriumwithasingleand/ormildprecipitatingfactor.Conversely,deliriummayonlyresultinhealthyindividualsiftheysufferseriousormultipleprecipitatingfactors.Itisimportanttonotethatthefactorsaffectingthoseofanindividualcanchangeovertime,thusanindividual’sriskofdeliriumisdynamic. Predisposingfactors[edit] Themostimportantpredisposingfactorsare:[21] 65ormoreyearsofage Malesex Cognitiveimpairment/dementia Physicalcomorbidity(biventricularfailure,cancer,cerebrovasculardisease) Psychiatriccomorbidity(e.g.,depression) Sensoryimpairment(vision,hearing) Functionaldependence(e.g.,requiringassistanceforself-careormobility) Dehydration/malnutrition Drugsanddrug-dependence Alcoholdependence Precipitatingfactors[edit] Acuteconfusionalstatecausedbyalcoholwithdrawal,alsoknownasdeliriumtremens Anyacutefactorsthataffectneurotransmitter,neuroendocrine,orneuroinflammatorypathwayscanprecipitateanepisodeofdeliriuminavulnerablebrain.[22]Clinicalenvironmentscanalsoprecipitatedelirium.[23]Someofthemostcommonprecipitatingfactorsarelistedbelow:[24] Prolongedsleepdeprivation Environmental,physical/psychologicalstress Inadequatelycontrolledpain Admissiontoanintensivecareunit Immobilization,useofphysicalrestraints[25] Urinaryretention,useofbladdercatheter, Emotionalstress Severeconstipation/fecalimpaction Medications[26][27] Sedatives(benzodiazepines,opioids),anticholinergics,dopaminergics,corticosteroids,polypharmacy Generalanesthetic Substanceintoxicationorwithdrawal Primaryneurologicdiseases Severedropinbloodpressure,relativetothepatient’snormalbloodpressure(orthostatichypotension)resultingininadequatebloodflowtothebrain(cerebralhypoperfusion) Stroke/Transientischemicattack(TIA) Intracranialbleeding Meningitis,encephalitis Concurrentillness Infections–especiallyrespiratory(e.g.pneumonia,COVID-19[28])andurinarytractinfections Iatrogeniccomplications Hypoxia,hypercapnea,anemia Poornutritionalstatus,dehydration,electrolyteimbalances,hypoglycemia Shock,heartattacks,heartfailure Metabolicderangements(e.g.SIADH,Addison’sdisease,hyperthyroidism,) Chronic/terminalillness(e.g.cancer) Post-traumaticevent(e.g.fall,fracture) Mercurypoisoning(e.g.Erethism) Surgery Cardiac,orthopedic,prolongedcardiopulmonarybypass,thoracicsurgeries Pathophysiology[edit] Thepathophysiologyofdeliriumisstillnotwellunderstood,despiteextensiveresearch. Animalmodels[edit] Thelackofanimalmodelsthatarerelevanttodeliriumhasleftmanykeyquestionsindeliriumpathophysiologyunanswered.Earliestrodentmodelsofdeliriumusedatropine(amuscarinicacetylcholinereceptorblocker)toinducecognitiveandelectroencephalography(EEG)changessimilartodelirium,andotheranticholinergicdrugs,suchasbiperidenandhyoscine,haveproducedsimilareffects.Alongwithclinicalstudiesusingvariousdrugswithanticholinergicactivity,thesemodelshavecontributedtoa"cholinergicdeficiencyhypothesis"ofdelirium.[29] Profoundsystemicinflammationoccurringduringsepsisisalsoknowntocausedelirium(oftentermedsepsis-associatedencephalopathy).[30]Animalmodelsusedtostudytheinteractionsbetweenpriordegenerativediseaseandoverlyingsystemicinflammationhaveshownthatevenmildsystemicinflammationcausesacuteandtransientdeficitsinworkingmemoryamongdiseasedanimals.[31]Priordementiaorage-associatedcognitiveimpairmentistheprimarypredisposingfactorforclinicaldeliriumand"priorpathology"asdefinedbythesenewanimalmodelsmayconsistofsynapticloss,abnormalnetworkconnectivity,and"primedmicroglia"brainmacrophagesstimulatedbypriorneurodegenerativediseaseandagingtoamplifysubsequentinflammatoryresponsesinthecentralnervoussystem(CNS).[31] Cerebrospinalfluid[edit] Studiesofcerebrospinalfluid(CSF)indeliriumaredifficulttoperform.Apartfromthegeneraldifficultyofrecruitingparticipantswhoareoftenunabletogiveconsent,theinherentlyinvasivenatureofCSFsamplingmakessuchresearchparticularlychallenging.However,afewstudieshaveexploitedtheopportunitytosampleCSFfrompersonsundergoingspinalanesthesiaforelectiveoremergencysurgery. A2018systematicreviewshowedthat,broadly,deliriummaybeassociatedwithneurotransmitterimbalance(namelyserotoninanddopaminesignaling),reversiblefallinsomatostatin,andincreasedcortisol.[32]Theleading"neuroinflammatoryhypothesis"(whereneurodegenerativediseaseandagingleadsthebraintorespondtoperipheralinflammationwithanexaggeratedCNSinflammatoryresponse)hasbeendescribed,[33]butcurrentevidenceisstillconflictingandfailstoconcretelysupportthishypothesis.[32] Neuroimaging[edit] Neuroimagingprovidesanimportantavenuetoexplorethemechanismsthatareresponsiblefordelirium.[34][35]Despiteprogressinthedevelopmentofmagneticresonanceimaging(MRI),thelargevarietyinimaging-basedfindingshaslimitedourunderstandingofthechangesinthebrainthatmaybelinkedtodelirium.Somechallengesassociatedwithimagingpeoplediagnosedwithdeliriumincludeparticipantrecruitmentandinadequateconsiderationofimportantconfoundingfactorssuchashistoryofdementiaand/ordepression,whichareknowntobeassociatedwithoverlappingchangesinthebrainalsoobservedonMRI.[34] Evidenceforchangesinstructuralandfunctionalmarkersinclude:changesinwhite-matterintegrity(whitematterlesions),decreasesinbrainvolume(likelyasaresultoftissueatrophy),abnormalfunctionalconnectivityofbrainregionsresponsiblefornormalprocessingofexecutivefunction,sensoryprocessing,attention,emotionalregulation,memory,andorientation,differencesinautoregulationofthevascularvesselsinthebrain,reductionincerebralbloodflowandpossiblechangesinbrainmetabolism(includingcerebraltissueoxygenationandglucosehypometabolism).[34][35]Altogether,thesechangesinMRI-basedmeasurementsinvitefurtherinvestigationofthemechanismsthatmayunderliedelirium,asapotentialavenuetoimproveclinicalmanagementofpeoplesufferingwiththiscondition.[34] Neurophysiology[edit] Electroencephalography(EEG)allowsforcontinuouscaptureofglobalbrainfunctionandbrainconnectivity,andisusefulinunderstandingreal-timephysiologicchangesduringdelirium.[36]Sincethe1950s,deliriumhasbeenknowntobeassociatedwithslowingofresting-stateEEGrhythms,withabnormallydecreasedbackgroundalphapowerandincreasedthetaanddeltafrequencyactivity.[36][37] Fromsuchevidence,a2018systematicreviewproposedaconceptualmodelthatdeliriumresultswheninsults/stressorstriggerabreakdownofbrainnetworkdynamicsinindividualswithlowbrainresilience(i.e.peoplewhoalreadyhaveunderlyingproblemsoflowneuralconnectivityand/orlowneuroplasticitylikethosewithAlzheimer'sdisease).[36] Neuropathology[edit] Onlyahandfulofstudiesexistwheretherehasbeenanattempttocorrelatedeliriumwithpathologicalfindingsatautopsy.Oneresearchstudyhasbeenreportedon7patientswhodiedduringICUadmission.[38]Eachcasewasadmittedwitharangeofprimarypathologies,butallhadacuterespiratorydistresssyndromeand/orsepticshockcontributingtothedelirium,6showedevidenceoflowbrainperfusionanddiffusevascularinjury,and5showedhippocampalinvolvement.Acase-controlstudyshowedthat9deliriumcasesshowedhigherexpressionofHLA-DRandCD68(markersofmicroglialactivation),IL-6(cytokinespro-inflammatoryandanti-inflammatoryactivities)andGFAP(markerofastrocyteactivity)thanage-matchedcontrols;thissupportsaneuroinflammatorycausetodelirium,buttheconclusionsarelimitedbymethodologicalissues.[39] A2017retrospectivestudycorrelatingautopsydatawithMMSEscoresfrom987braindonorsfoundthatdeliriumcombinedwithapathologicalprocessofdementiaacceleratedMMSEscoredeclinemorethaneitherindividualprocess.[40] Diagnosis[edit] UsingtheDSM-5criteriafordeliriumasframework,theearlyrecognitionofsigns/symptomsandacarefulhistory,alongwithanyofmultipleclinicalinstruments,canhelpinmakingadiagnosisofdelirium.Adiagnosisofdeliriumcannotbemadewithoutapreviousassessmentofthepatient'sbaselinelevelofcognitivefunction.Inotherwords,amentally-disabledordementedpersonmightappeartobedelirious,butmayactuallyjustbeoperatingathis/herbaselinementalability. Generalsetting[edit] Multipleguidelinesrecommendthatdeliriumshouldbediagnosedwhenitpresentstohealthcareservices.Muchevidencereveal,however,thatdeliriumisgreatlyunder-diagnosed.[41][42][43]Higherratesofdetectionofdeliriumingeneralsettingscanbeassistedbytheuseofvalidateddeliriumscreeningtools.Manysuchtoolshavebeenpublished.Theydifferinduration,complexity,needfortraining,etc. Examplesoftoolsinuseinclinicalpracticeare: RichmondAgitationandSedationScale(RASS)–highlysensitiveandspecificfordiagnosingdeliriuminolderpatients[44][45] ObservationalScaleofLevelofArousal(OSLA)–highlysensitiveandspecificfordiagnosingdeliriuminolderpatients[44][46] ConfusionAssessmentMethod(CAM)[47] DeliriumObservationScreeningScale(DOS)[48] NursingDeliriumScreeningScale(Nu-DESC)[49] RecognizingAcuteDeliriumAspartofyourRoutine(RADAR)[50] 4AT(4A'sTest)[51][52] DeliriumDiagnosticTool-Provisional(DDT-Pro),[53][54]alsoforsubsyndromaldelirium[55] Intensivecareunit[edit] PeoplewhoareintheICUareatgreaterriskofdeliriumandICUdeliriummayleadtoprolongedventilation,longerstaysinthehospital,increasedstressonfamilyandcaregivers,andanincreasedchanceofdeath.[56]IntheICU,internationalguidelinesrecommendthateverypatientgetscheckedfordeliriumeveryday(usuallytwiceormoreaday)usingavalidatedclinicaltool.[57]Thedefinitionofdeliriumthathealthcareprofessionalsuseatthebedsideiswhetherornotapatientcanpayattentionandfollowsimplecommands.[58]ThetwomostwidelyusedaretheConfusionAssessmentMethodfortheICU(CAM-ICU)[59]andtheIntensiveCareDeliriumScreeningChecklist(ICDSC).[60]Translationsofthesetoolsexistinover20languagesandareusedICUsgloballywithinstructionalvideosandimplementationtipsavailable.[58] Moreemphasisisplacedonregularscreeningoverthechoiceoftoolused.This,coupledwithproperdocumentationandinformedawarenessbythehealthcareteam,canaffectclinicaloutcomes.[58]Withoutusingoneofthesetools,75%ofICUdeliriumcanbemissedbythehealthcareteam,leavingthepatientwithoutanylikelyinterventionstohelpreducethedurationofdelirium.[58][61] Differentialdiagnosis[edit] Thereareconditionsthatmighthavesimilarclinicalpresentationstothoseseenindelirium.Theseincludedementia,[62][63][64][65][66]depression,[66][64]psychosis,[66][64]andotherconditionsthataffectcognitivefunction.[67] Dementia:Thisgroupofdisordersisacquired(non-congenital)withusuallyirreversiblecognitiveandpsychosocialfunctionaldecline.Dementiausuallyresultsfromanidentifiabledegenerativebraindisease(e.g.AlzheimerdiseaseorHuntington'sdisease),requireschronicimpairment(versusacuteonsetindelirium),andistypicallynotassociatedwithchangesinlevelofconsciousness.[citationneeded] Depression:Similarsymptomsexistbetweendepressionanddelirium(especiallythehypoactivesubtype).Gatheringahistoryfromothercaregiverscanclarifybaselinementation.[68] Othermentalillnesses:Somementalillnesses,suchasamanicepisodeofbipolardisorder,depersonalizationdisorder,orsometypesofacutepsychosismaycausearapidlyfluctuatingimpairmentofcognitivefunctionandabilitytofocus.These,however,arenottechnicallycausesofdeliriumperDSM-5criteriaD(i.e.fluctuatingcognitivesymptomsoccurringaspartofaprimarymentaldisorderareresultsofthesaidmentaldisorderitself),whilephysicaldisorders(e.g.infections,hypoxia,etc.)canprecipitatedeliriumasamentalside-effect/symptom.[citationneeded] Psychosis:Consciousnessandcognitionmaynotbeimpaired(however,theremaybeoverlap,assomeacutepsychosis,especiallywithmania,iscapableofproducingdelirium-likestates).[citationneeded] Prevention[edit] Usingatailoredmulti-facetedapproachasoutlinedabovecandecreaseratesofdeliriumby27%amongtheelderly.[69][70]Atleast30–40%ofallcasesofdeliriumcouldbeprevented,andhighratesofdeliriumreflectnegativelyonthequalityofcare.[24]Episodesofdeliriumcanbepreventedbyidentifyinghospitalizedpeopleatriskofthecondition.Thisincludesindividualsoverage65,withacognitiveimpairment,withhipfracture,orwithsevereillness.[71]Closeobservationfortheearlysignsisrecommendedinsuchpopulations. Deliriummaybepreventedandtreatedbyusingnon-pharmacologicapproachesfocusedonriskfactors,suchasconstipation,dehydration,lowoxygenlevels,immobility,visualorhearingimpairment,sleepdeprivation,functionaldeclineandremovingorminimizingproblematicmedications.[71][64]Ensuringatherapeuticenvironment(e.g.individualizedcare;clearcommunication;adequatereorientationandlightingduringdaytime;promotinguninterruptedsleephygienewithminimalnoiseandlightatnight;minimizingbedrelocation;havingfamiliarobjectslikefamilypictures;providingearplugs;andprovidingadequatenutrition,paincontrol,andassistancetowardearlymobilization)canalsoyieldbenefittowardpreventingdelirium.[7][24][72][73]Researchintopharmacologicpreventionandtreatmentisweakandinsufficienttomakeproperrecommendations.[64] Melatoninandotherpharmacologicalagentshavebeenstudiedforpreventionofpostoperativedelirium,butevidenceisnotclear.[74][7]Avoidanceorcautioususeofbenzodiazepineshasbeenrecommendedforreducingtheriskofdeliriumincriticallyillindividuals.[75]Itisunclearifthemedicationdonepezil,acholinesteraseinhibitor,reducesdeliriumfollowingsurgery.[7]Thereisalsonoclearevidencetosuggestthatciticoline,methylprednisolone,orantipsychoticmedicationspreventdelirium.[7] Areviewofintravenousversusinhalationalmaintenanceofanaesthesiaforpostoperativecognitiveoutcomesinelderlypeopleundergoingnon-cardiacsurgeryshowedlittleornodifferenceinpostoperativedeliriumaccordingtothetypeofanaestheticmaintenanceagents[76]infivestudies(321participants).Theauthorsofthisreviewwereuncertainwhethermaintenanceofanaesthesiawithpropofol-basedtotalintravenousanaesthesia(TIVA)orwithinhalationalagentscanaffecttheincidencerateofpostoperativedelirium. Interventionsforpreventingdeliriuminolderpeopleininstitutionallong-termcare Thecurrentevidencesuggeststhatsoftware-basedinterventionstoidentifymedicationsthatcouldcontributetodeliriumriskandrecommendapharmacist'smedicationreviewprobablyreducesincidenceofdeliriuminolderadultsinlong-termcare.[77]Thebenefitsofhydrationremindersandeducationonriskfactorsandcarehomes'solutionsforreducingdeliriumisstilluncertain. Treatment[edit] Deliriumisareversibleimpairment,however,peoplethatareillwithdeliriummayneedtobetreatedinordertopreventinjuryandpooroutcomes.[56] Treatmentofdeliriumrequiresattentiontomultipledomainsincluding:identifyandtreattheunderlyingmedicaldisorderorcause(s),optimizephysiology,optimizeconditionsforbrainrecovery,detectandmanagedistressandbehavioraldisturbances,maintainingmobility,providerehabilitationthroughcognitiveengagementandmobilization,communicateeffectivelywiththepatientandtheircarers,andprovideadequatefollow-upincludingconsiderationofpossibledementiaandpost-traumaticstress.[1]Thisinvolvesoptimizingoxygenation,hydration,nutrition,electrolytes/metabolites,comfort,mobilization,paincontrol,mentalstress,therapeuticmedicationlevels,andaddressinganyotherpossiblepredisposingandprecipitatingfactorsthatmightbedisruptingbrainfunction.[24] Multidomaininterventions[edit] Theseinterventionsarethefirststepsinmanagingacutedeliriumandtherearemanyoverlapswithdeliriumpreventativestrategies.[78]Inadditiontotreatingimmediatelife-threateningcausesofdelirium(e.g.lowO2,lowbloodpressure,lowglucose,dehydration),interventionsincludeoptimizingthehospitalenvironmentbyreducingambientnoise,providingproperlighting,offeringpainrelief,promotinghealthysleep-wakecycles,andminimizingroomchanges.[78]Althoughmulticomponentcareandcomprehensivegeriatriccarearemorespecializedforapersonexperiencingdelirium,severalstudieshavebeenunabletofindevidenceshowingtheyreducethedurationofdelirium.[78] Family,friends,andothercaregiverscanofferfrequentreassurance,tactileandverbalorientation,cognitivestimulation(e.g.regularvisits,familiarobjects,clocks,calendars,etc.),andmeanstostayengaged(e.g.makinghearingaidsandeyeglassesreadilyavailable).[24][71][79]Sometimesverbalandnon-verbaldeescalationtechniquesmayberequiredtoofferreassurancesandcalmthepersonexperiencingdelirium.[71]Restraintsshouldrarelybeusedasaninterventionfordelirium.[80]Theuseofrestraintshasbeenrecognizedasariskfactorforinjuryandaggravatingsymptoms,especiallyinolderhospitalizedpeoplewithdelirium.[80]Theonlycaseswhererestraintsshouldsparinglybeusedduringdeliriumisintheprotectionoflife-sustaininginterventions,suchasendotrachealtubes.[80] Anotherapproachedcalledthe"T-A-DA(tolerate,anticipate,don'tagitate)method"canbeaneffectivemanagementtechniqueforolderpeoplewithdelirium,whereabnormalpatientbehaviors(includinghallucinationsanddelusions)aretoleratedandunchallenged,aslongascaregiverandpatientsafetyisnotthreatened.[81]Implementationofthismodelmayrequireadesignatedareainthehospital.Allunnecessaryattachmentsareremovedtoanticipateforgreatermobility,andagitationispreventedbyavoidingexcessivereorientation/questioning.[81] Medications[edit] Low-dosehaloperidolwhenusedshortterm(oneweekorless)isthemoststudiedandstandarddrugfordelirium.[24][71]Evidenceforefficacyofatypicalantipsychotics(i.e.risperidone,olanzapine,ziprasidone,andquetiapine)isemerging,withthebenefitforfewersideeffects[24][82]UseantipsychoticdrugswithcautionornotatallforpeoplewithconditionssuchasParkinson'sdiseaseordementiawithLewybodies.[83]Evidencefortheeffectivenessofmedications(includingantipsychoticsandbenzodiazepines)intreatingdeliriumisweak.[63][56] Benzodiazepinesthemselvescantriggerorworsendelirium,andthereisnoreliableevidenceforuseinnon-alcohol-relateddelirium.[84]Ifthedeliriuminvolvesalcoholwithdrawal,benzodiazepinewithdrawal,orcontraindicationstoantipsychotics(e.g.inParkinson'sdiseaseorneurolepticmalignantsyndrome),thenbenzodiazepinesarerecommended.[84]Similarly,peoplewithdementiawithLewybodiesmayhavesignificantsideeffectstoantipsychotics,andshouldeitherbetreatedwithanoneorsmalldosesofbenzodiazepines.[71] Theantidepressanttrazodoneisoccasionallyusedinthetreatmentofdelirium,butitcarriesariskofover-sedation,anditsusehasnotbeenwellstudied.[24] ForadultswithdeliriumthatareintheICU,medicationsareusedcommonlytoimprovethesymptoms.Dexmedetomidinemayshortenthelengthofthedeliriuminadultswhoarecriticallyillandrivastigmineisnotsuggested.[56]Foradultswithdeliriumwhoareneartheendoftheirlife(onpalliativecare)highqualityevidencetosupportorrefutetheuseofmostmedicationstotreatdeliriumisnotavailable.[85]Lowqualityevidenceindicatesthattheantipsychoticmedicationsrisperidoneorhaloperidolmaymakethedeliriumslightlyworseinpeoplewhoareterminiallyill,whencomparedtoaplacebotreatment.[85]Thereisalsomoderatetolowqualityevidencetosuggestthathaloperidolandrisperidonemaybeassociatedwithaslightincreaseinsideeffects,specificallyextrapyramidolsymptoms,ifthepersonneartheendoftheirlifehasdeliriumthatismildtomoderateinseverity.[85] Prognosis[edit] Thereissubstantialevidencethatdeliriumresultsinlong-termpooroutcomesinolderpersonsadmittedtohospital.[86]Thissystematicreviewonlyincludedstudiesthatlookedforanindependenteffectofdelirium(i.e.,afteraccountingforotherassociationswithpooroutcomes,forexampleco-morbidityorillnessseverity). Inolderpersonsadmittedtohospital,individualsexperiencingdeliriumaretwiceaslikelytodiethanthosewhodonot(meta-analysisof12studies).[86]Intheonlyprospectivestudyconductedinthegeneralpopulation,olderpersonsreportingdeliriumalsoshowedhighermortality(60%increase).[87] Institutionalizationwasalsotwiceaslikelyafteranadmissionwithdelirium(meta-analysisof7studies).[86]Inacommunity-basedpopulationexaminingindividualsafteranepisodeofsevereinfection(thoughnotspecificallydelirium),thesepersonsacquiredmorefunctionallimitations(i.e.requiredmoreassistancewiththeircareneeds)thanthosenotexperiencinginfection.[88]Afteranepisodeofdeliriuminthegeneralpopulation,functionaldependenceincreasedthreefold.[87] Theassociationbetweendeliriumanddementiaiscomplex.Thesystematicreviewestimateda13-foldincreaseindementiaafterdelirium(meta-analysisof2studies).[86]However,itisdifficulttobecertainthatthisisaccuratebecausethepopulationadmittedtohospitalincludespersonswithundiagnoseddementia(i.e.thedementiawaspresentbeforethedelirium,ratherthancausedbyit).Inprospectivestudies,peoplehospitalisedfromanycauseappeartobeatgreaterriskofdementia[89]andfastertrajectoriesofcognitivedecline,[89][90]butthesestudiesdidnotspecificallylookatdelirium.Intheonlypopulation-basedprospectivestudyofdelirium,olderpersonshadaneight-foldincreaseindementiaandfastercognitivedecline.[87]ThesameassociationisalsoevidentinpersonsalreadydiagnosedwithAlzheimer'sdementia.[91] Recentlong-termstudiesshowedthatmanypatientsstillmeetcriteriafordeliriumforaprolongedperiodafterhospitaldischarge,withupto21%ofpatientsshowingpersistentdeliriumat6monthspost-discharge.[92] DementiainICUsurvivors[edit] Seealso:Post-intensivecaresyndrome Dementiaissupposedtobeanentitythatcontinuestodecline,suchasAlzheimer'sdisease.Anotherwayoflookingatdementia,however,isnotstrictlybasedonthedeclinecomponent,butonthedegreeofmemoryandexecutivefunctionproblems.Itisnowknown,forexample,thatbetween50%and70%ofICUpatientshavetremendousproblemswithongoingbraindysfunctionsimilartothoseexperiencedbyAlzheimer'sorTBI(traumaticbraininjury)patients,leavingmanyICUsurvivorspermanentlydisabled.[93]Thisisadistressingpersonalandpublichealthproblemandisgettinganincreasingamountofscrutinyinongoinginvestigations.[citationneeded] Theimplicationsofsuchan"acquireddementia-likeillness"canprofoundlydebilitateaperson'slivelihoodlevel,oftendismantlinghis/herlifeinpracticalwayslikeimpairingone'sabilitytofindacarinaparkinglot,completeshoppinglists,orperformjob-relatedtasksdonepreviouslyforyears.[citationneeded]Thesocietalimplicationscanbeenormouswhenconsideringwork-forceissuesrelatedtotheinabilityofwage-earnerstoworkduetotheirownICUstayorthatofsomeoneelsetheymustcarefor.[94] Epidemiology[edit] Thehighestratesofdelirium(often50%to75%ofpeople)isseenamongthosewhoarecriticallyillintheintensivecareunit(ICU)[95]Asaresult,thiswasreferredtoas"ICUpsychosis"or"ICUsyndrome",termslargelyabandonedforthemorewidelyacceptedtermICUdelirium.Sincetheadventofvalidatedandeasy-to-implementdeliriuminstrumentsforICUpatientssuchastheConfusionAssessmentMethodfortheICU(CAM-ICU)[59]andtheIntensiveCareDeliriumScreeningCheckllist(IC-DSC).,[60]ofthehundredsofthousandsofICUpatientswhodevelopdeliriuminICUseveryyear,ithasbeenrecognizedthatmostofthembelongtothehypoactivevariety,whichiseasilymissedandinvisibletothemanagingteamsunlessactivelymonitoredusingsuchinstruments.Thecausesofdeliriuminsuchpatientsdependontheunderlyingillnesses,newproblemslikesepsisandlowoxygenlevels,andthesedativeandpainmedicinesthatarenearlyuniversallygiventoallICUpatients.OutsidetheICU,onhospitalwardsandinnursinghomes,theproblemofdeliriumisalsoaveryimportantmedicalproblem,especiallyforolderpatients.[96] ThemostrecentareaofthehospitalinwhichdeliriumisjustbeginningtobemonitoredroutinelyinmanycentersistheEmergencyDepartment,wheretheprevalenceofdeliriumamongolderadultsisabout10%.[97]Asystematicreviewofdeliriumingeneralmedicalinpatientsshowedthatestimatesofdeliriumprevalenceonadmissionrangedfrom10to31%.[98]About5%to10%ofolderadultswhoareadmittedtohospitaldevelopanewepisodeofdeliriumwhileinhospital.[97]Ratesofdeliriumvarywidelyacrossgeneralhospitalwards.[99]Estimatesoftheprevalenceofdeliriuminnursinghomesarebetween10%[97]to45%.[100] Societyandculture[edit] Deliriumisoneoftheoldestformsofmentaldisorderknowninmedicalhistory.[101]TheRomanauthorAulusCorneliusCelsususedthetermtodescribementaldisturbancefromheadtraumaorfeverinhisworkDeMedicina.[102] EnglishmedicalwriterPhilipBarrownotedin1583thatifdelirium(or"frenisy")resolves,itmaybefollowedbyalossofmemoryandreasoningpower.[103] Sims(1995,p. 31)pointsouta"superbdetailedandlengthydescription"ofdeliriumin"TheStroller'sTale"fromCharlesDickens'ThePickwickPapers.[104][105] TheAmericanDeliriumSocietyisacommunityofprofessionalsdedicatedtoimprovingdeliriumcare."[106]TheCriticalIllness,BrainDysfunction,andSurvivorship(CIBS)Centerisanacademiccenterdedicatedtostudyingandtreatingdeliriumincriticallyillpatientpopulations.[58] Costs[edit] IntheUS,thecostofapatientadmissionwithdeliriumisestimatedatbetween$16kand$64k,suggestingthenationalburdenofdeliriummayrangefrom$38bnto$150bnperyear(2008estimate).[107]IntheUK,thecostisestimatedas£13kperadmission.[108] References[edit] ^abcWilson,JoEllen;Mart,MatthewF.;Cunningham,Colm;Shehabi,Yahya;Girard,TimothyD.;MacLullich,AlasdairM.J.;Slooter,ArjenJ.C.;Ely,E.Wesley(2020-11-12)."Delirium".NatureReviews.DiseasePrimers.6(1):90.doi:10.1038/s41572-020-00223-4.ISSN 2056-676X.PMID 33184265.S2CID 226302415. 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Furtherreading[edit] MacdonaldA,LindesayJ,RockwoodK(2002).Deliriuminoldage.Oxford[Oxfordshire]:OxfordUniversityPress.ISBN 978-0-19-263275-3. GrassiL,CaraceniA(2003).Delirium:acuteconfusionalstatesinpalliativemedicine.Oxford:OxfordUniversityPress.ISBN 978-0192631992. NewmanJK,SlaterCT,eds.(2012).Delirium:causes,diagnosisandtreatment.Hauppauge,N.Y.:NovaSciencePublisher's,Inc.ISBN 978-1613242940. Externallinks[edit] Wikisourcehasthetextofthe1911EncyclopædiaBritannicaarticle"Delirium". ClassificationDICD-10:F05ICD-9-CM:780.09MeSH:D003693DiseasesDB:29284ExternalresourcesMedlinePlus:000740eMedicine:med/3006PatientUK:Delirium vteMentalandbehavioraldisordersAdultpersonalityandbehaviorSexual Ego-dystonicsexualorientation Paraphilia Fetishism Voyeurism Sexualmaturationdisorder Sexualrelationshipdisorder Other Factitiousdisorder Munchausensyndrome Genderdysphoria Intermittentexplosivedisorder Dermatillomania Kleptomania Pyromania Trichotillomania Personalitydisorder ChildhoodandlearningEmotionalandbehavioral ADHD Conductdisorder ODD Emotionalandbehavioraldisorders Separationanxietydisorder Movementdisorders Stereotypic Socialfunctioning DAD RAD Selectivemutism Speech Cluttering Stuttering Ticdisorder Tourettesyndrome Intellectualdisability X-linkedintellectualdisability Lujan–Frynssyndrome Psychologicaldevelopment(developmentaldisabilities) Pervasive Specific Mood(affective) Bipolar BipolarI BipolarII BipolarNOS Cyclothymia Depression Atypicaldepression Dysthymia Majordepressivedisorder Melancholicdepression Seasonalaffectivedisorder Mania NeurologicalandsymptomaticAutismspectrum Autism Aspergersyndrome High-functioningautism PDD-NOS Savantsyndrome Dementia AIDSdementiacomplex Alzheimer'sdisease Creutzfeldt–Jakobdisease Frontotemporaldementia Huntington'sdisease Mildcognitiveimpairment Parkinson'sdisease Pick'sdisease Sundowning Vasculardementia Wandering Other Delirium Organicbrainsyndrome Post-concussionsyndrome Neurotic,stress-relatedandsomatoformAdjustment Adjustmentdisorderwithdepressedmood AnxietyPhobia Agoraphobia Socialanxiety Socialphobia Anthropophobia Specificsocialphobia Specificphobia Claustrophobia Other Generalizedanxietydisorder OCD Panicattack Panicdisorder Stress Acutestressdisorder PTSD Dissociative Depersonalization-derealizationdisorder Dissociativeidentitydisorder Fuguestate Psychogenicamnesia Somaticsymptom Bodydysmorphicdisorder Conversiondisorder Gansersyndrome Globuspharyngis Psychogenicnon-epilepticseizures Falsepregnancy Hypochondriasis Masspsychogenicillness Nosophobia Psychogenicpain Somatizationdisorder PhysiologicalandphysicalbehaviorEating Anorexianervosa Bulimianervosa Ruminationsyndrome Otherspecifiedfeedingoreatingdisorder Nonorganicsleep Hypersomnia Insomnia Parasomnia Nightterror Nightmare REMsleepbehaviordisorder Postnatal Postpartumdepression Postpartumpsychosis SexualdysfunctionArousal Erectiledysfunction Femalesexualarousaldisorder Desire Hypersexuality Hypoactivesexualdesiredisorder Orgasm Anorgasmia Delayedejaculation Prematureejaculation Sexualanhedonia Pain Nonorganicdyspareunia Nonorganicvaginismus Psychoactivesubstances,substanceabuseandsubstance-related Drugoverdose Intoxication Physicaldependence Reboundeffect Stimulantpsychosis Substancedependence Withdrawal Schizophrenia,schizotypalanddelusionalDelusional Delusionaldisorder Folieàdeux Psychosisandschizophrenia-like Briefreactivepsychosis Schizoaffectivedisorder Schizophreniformdisorder Schizophrenia Childhoodschizophrenia Disorganized(hebephrenic)schizophrenia Paranoidschizophrenia Pseudoneuroticschizophrenia Simple-typeschizophrenia Other Catatonia Symptomsanduncategorized Impulse-controldisorder Klüver–Bucysyndrome Psychomotoragitation Stereotypy Retrievedfrom"https://en.wikipedia.org/w/index.php?title=Delirium&oldid=1053469845" Categories:CognitivedisordersIntensivecaremedicinePsychopathologicalsyndromesHiddencategories:CS1maint:DOIinactiveasofOctober2021CS1maint:othersAllpagesneedingfactualverificationWikipediaarticlesneedingfactualverificationfromSeptember2019ArticleswithshortdescriptionShortdescriptionisdifferentfromWikidataAllarticleswithunsourcedstatementsArticleswithunsourcedstatementsfromOctober2019 Navigationmenu Personaltools NotloggedinTalkContributionsCreateaccountLogin Namespaces ArticleTalk Variants expanded collapsed Views ReadEditViewhistory More expanded collapsed Search Navigation MainpageContentsCurrenteventsRandomarticleAboutWikipediaContactusDonate Contribute HelpLearntoeditCommunityportalRecentchangesUploadfile Tools WhatlinkshereRelatedchangesUploadfileSpecialpagesPermanentlinkPageinformationCitethispageWikidataitem Print/export DownloadasPDFPrintableversion Inotherprojects WikimediaCommons Languages AlemannischالعربيةAzərbaycancaBosanskiCatalàČeštinaDanskDeutschEestiΕλληνικάEspañolEsperantoEuskaraفارسیFrançaisGaeilgeગુજરાતી한국어हिन्दीBahasaIndonesiaItalianoעבריתಕನ್ನಡKurdîLatinaLatviešuМакедонскиBahasaMelayuNederlands日本語Norskbokmålଓଡ଼ିଆPolskiPortuguêsРусскийSimpleEnglishSlovenščinaСрпски/srpskiSrpskohrvatski/српскохрватскиSuomiSvenskaTagalogไทยTürkçeУкраїнська中文 Editlinks