Definition

Delirium is a mental condition characterized by confusion in thinking and reduced awareness of the environment. This condition is usually temporary and can return to normal. Delirium typically arises suddenly within a few hours or days. It can occur at any age but is more common in the elderly or those with a history of mental disorders.

Many factors can influence delirium, such as severe or prolonged illness, electrolyte imbalances (like low sodium levels), medications, infections, surgery, alcohol, drug poisoning, or withdrawal symptoms.

The symptoms of delirium are similar to dementia, so information from family members about changes in the patient's condition will help doctors make an accurate diagnosis.

Causes

Delirium occurs when the transmission and reception of signals in the brain are disrupted. This can be caused by various factors that make the brain vulnerable and trigger impaired brain activity.

Delirium can have one or more causes, such as a combination of medical conditions and drug toxicity. However, sometimes no cause can be found for delirium. Some possible causes include:

• Certain medications or drug poisoning
• Alcohol or drug withdrawal
• Specific medical conditions, such as stroke, heart attack, worsening lung or liver disease, and injuries from falls
• Electrolyte imbalances, like low sodium or calcium levels
• Severe end-stage diseases
• Acute infections and fever, especially in children
• Urinary tract infections, lung infections, especially in the elderly
• Carbon monoxide poisoning, cyanide, or other toxins
• Malnutrition or dehydration
• Lack of sleep or severe emotional stress
• Pain
• Surgery or other medical procedures involving anesthesia
• Several medications or combinations of drugs that can trigger delirium, such as:
• Painkillers
• Sleeping pills
• Mood disorder medications, like those for anxiety and depression
• Allergy medications (antihistamines)
• Asthma medications
• Anti-inflammatory steroids
• Parkinson's disease medications
• Seizure medications

Risk factor

Any condition requiring hospitalization, especially in intensive care or after surgery, can increase the risk of delirium. This is also true for elderly care in nursing homes. Delirium is more common in the elderly. Other conditions that increase the risk of delirium include:

• Brain disorders such as dementia, stroke, or Parkinson's disease
• Previous history of delirium
• Vision or hearing problems
• Other medical issues

Symptoms

Delirium signs and symptoms usually appear within a few hours or days. These signs and symptoms can fluctuate throughout the day, often worsening at night. Key signs and symptoms include:

• Reduced awareness of the environment:
• Inability to focus on a topic or switch topics
• Getting stuck on an idea and having difficulty responding to questions or conversations
• Easily distracted by unimportant things
• Withdrawing with little or no response to the environment
• Poor thinking skills (cognitive impairment):
• Poor memory, especially of recent events
• Disorientation, such as not knowing where you are or who you are
• Difficulty speaking or remembering words
• Slurred speech
• Difficulty understanding speech
• Difficulty reading or writing
• Behavioral changes:
• Seeing things that aren't there (hallucinations)
• Restlessness, agitation, or aggressive behavior
• Calling out, moaning, or making other sounds
• Becoming quiet and withdrawn, especially in the elderly
• Slow or lethargic movements
• Disturbed sleep patterns
• Reversed sleep-wake cycle
• Emotional disturbances:
• Anxiety or fear
• Depression
• Irritability or easy anger
• Euphoria
• Apathy
• Rapid and unpredictable mood changes
• Personality changes

Experts have identified three types of delirium:

1. Hyperactive delirium: The most easily recognized type, characterized by restlessness, agitation, rapid mood changes, hallucinations, and difficulty calming down.
2. Hypoactive delirium: Symptoms include reduced or inactive motor activity, lethargy, abnormal drowsiness, or seeming confusion.
3. Mixed delirium: Symptoms include both hyperactive and hypoactive types, with the patient quickly shifting from one state to another.

Diagnosis

A doctor can diagnose delirium based on medical history, mental status tests, and identification of possible contributing factors. The assessment includes:

• Mental status assessment: Evaluating the patient's awareness, attention, and thinking, which can be done informally through conversation or through mental status screening, perception, and memory tests.
• Physical and neurological examination: The doctor conducts a physical exam to check for underlying signs of disease. Neurological examinations, such as vision, balance, coordination, and reflex tests, can help determine if stroke or other neurological diseases are causing delirium.
• Other tests: Blood tests, urine tests, or other diagnostic tests may be performed. Brain imaging tests may be done if the diagnosis cannot be established with the available information.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the diagnostic criteria for delirium include:

• Attention disturbances, such as difficulty maintaining attention, and reduced awareness of the environment
• Cognitive changes, including memory impairment, disorientation, and language disturbances
• Rapid onset of symptoms and fluctuations throughout the day
• Evidence that the disturbances are due to the physiological effects of a medical condition, substance intoxication, or withdrawal

Management

The first goal of treating delirium is to address the underlying cause or trigger, such as stopping the use of certain medications, correcting electrolyte imbalances, or treating infections. Treatment then focuses on creating a conducive environment for healing and calming the patient's mind.

Supportive Care

Supportive care aims to prevent complications by:

• Protecting the airway
• Providing fluids and nutrition
• Assisting with movement
• Managing pain
• Addressing incontinence
• Avoiding physical restraints
• Minimizing changes in environment and caregivers whenever possible
• Encouraging family involvement or familiar people to help improve the patient's communication skills

Medications

If you are a family member or caregiver of a patient with delirium, consult with the doctor about which medications can trigger delirium. Certain medications may be needed to reduce pain, which can cause delirium.

Other medications can help calm an agitated, confused patient or one who misinterprets the environment leading to fear or severe hallucinations. These medications are usually required when the patient might harm themselves or others. The doses of these medications will be reduced or stopped when delirium symptoms disappear.

Complications

Delirium can last only a few hours, weeks, or even months. If the underlying issue causing delirium is addressed, recovery will be quicker. The recovery rate depends on the health and mental status before delirium. For instance, people with dementia may experience significant memory and thinking ability declines after recovering from delirium. Those in better health are more likely to recover fully.

In severely ill, chronic, or end-stage patients, previously held thinking skills or functions may not return to normal. Delirium in severely ill patients is more likely to lead to overall health decline, poor postoperative recovery, the need for routine care, and an increased risk of death.

Prevention

The most important step in preventing delirium is addressing the triggers. The hospital environment can be a trigger for delirium due to room changes, invasive procedures, noise, poor lighting due to lack of natural light, and difficulty sleeping for some patients. Educating about good habits and sleep practices can help patients stay calm and oriented, and preventing or mitigating medical issues or other complications can help prevent or reduce the severity of delirium.

If you are a family member or caregiver of a patient at risk or recovering from delirium, you can take the following steps to help improve the patient's health and prevent delirium recurrence:

• Support good sleep habits:
• Keep the environment calm
• Ensure the room is well-lit
• Maintain a disturbance-free sleep atmosphere
• Help the patient establish a regular daily routine
• Encourage self-care and normal daily activities during the day
• Maintain calmness and orientation:
• Provide clocks and calendars and explain the time and date
• Simply explain any changes in activities, such as meal times or bedtimes
• Keep familiar objects or pictures close by, but avoid clutter
• Communicate gently
• Regularly remind the patient of who you are and others around them
• Avoid arguments
• Provide comfort through soothing touch if needed
• Minimize noise and other disturbances
• Provide glasses and hearing aids
• Prevent complications:
• Administer medications accurately and on schedule
• Ensure adequate fluid intake and a healthy diet
• Encourage regular physical activity
• Provide immediate care for potential issues such as infections or electrolyte imbalances

Caring for someone with delirium can be daunting and exhausting. Therefore, it is also essential to pay attention to the caregiver's health by:

• Joining support groups for caregivers of delirium patients
• Learning more about the patient's condition
• Seeking information on patient care or assistance from healthcare workers, nonprofit organizations, public health services, or government agencies
• Asking for help from other family members known to the patient so you can take a break

When to see a doctor?

If a family member, friend, or someone you care for has signs or symptoms of delirium, see your doctor right away. Your account of the symptoms, how the person thinks and communicates, and how well they function will be important information in making a proper diagnosis and finding the cause.

Older patients who are hospitalized or living in long-term care facilities (such as nursing homes) are at high risk for delirium. If you notice signs and symptoms of delirium in someone in the hospital or nursing home, report them to the nursing staff or doctor right away.

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