Delirium

As delirium acute, transient, usually reversible fluctuating disturbance in attention, cognition and consciousness levels is called. The causes include almost any disease or drug reaction. The diagnosis is clinical, laboratory tests and imaging techniques commonly used to determine the cause. The treatment is to correct the underlying disorder and supportive measures.

Delirium can occur at any age, but is more common in older patients. At least 10% of older patients who are admitted to a hospital have delirium; 15-50% experience delirium at some point during a hospital stay. Delirium is also common after surgery and residents of nursing homes and patients in intensive care. If delirium occurs in younger patients, it is usually caused by drug use or a life-threatening systemic disease.

As delirium acute, transient, usually reversible fluctuating disturbance in attention, cognition and consciousness levels is called. The causes include almost any disease or drug reaction. The diagnosis is clinical, laboratory tests and imaging techniques commonly used to determine the cause. The treatment is to correct the underlying disorder and supportive measures. Delirium can occur at any age, but is more common in older patients. At least 10% of older patients who are admitted to a hospital have delirium; 15-50% experience delirium at some point during a hospital stay. Delirium is also common after surgery and residents of nursing homes and patients in intensive care. If delirium occurs in younger patients, it is usually caused by drug use or a life-threatening systemic disease. Delirium is sometimes called acute confusional state or toxic or metabolic encephalopathy. Delirium and dementia are different disorders, but that can be difficult to distinguish from each other sometimes. In both cognition is impaired; but helps to distinguish these following a Dellir mainly affects the attention that is usually caused by an acute illness or drug or drug toxicity (sometimes fatal) and is often reversible. Dementia mainly affects memory, is usually caused by anatomical changes in the brain shows a slow start and is usually irreversible. Other characteristics also help to distinguish the two disorders (see Table: Differences Between Delirium and Dementia *). Etiology The most common causes of delirium are: drugs, particularly anticholinergics, psychoactive substances and opioids dehydration infection Many other disorders can cause delirium (see Table: Causes of delirium). In 10-20% of patients no cause can be identified. Predisposing factors are brain disorders (eg. As dementia, stroke, Parkinson’s disease), advanced age, sensory disturbances (eg. As impaired vision or hearing), alcohol intoxication and multiple comorbidities. Triggering factors are: use of drugs (in particular ? 3 new drugs), infection, dehydration, shock, hypoxia, anemia, immobility, malnutrition, use of urinary catheters (with or without urinary retention), hospitalization, pain, sleep deprivation and emotional stress. Unrecognized liver or renal failure may cause drug toxicity and delirium by impaired metabolism and clearance of a previously well-tolerated drug is reduced. A recent exposure to anesthetics also increases the risk, especially if the drug has lasted a long time and when given during surgery anticholinergics. Postoperative pain and the use of opioid analgesics can contribute to delirium. Reduced sensory stimuli at night can trigger delirium in patients at risk. For older patients in an intensive care the risk of delirium is particularly high (transitional syndrome). Nonkonvulsiver status epilepticus is increasingly recognized as a cause of altered mental status in intensive care patients. Causes of delirium category Examples Neurological causes cerebrovascular disorders hemorrhagic stroke, ischemic stroke, transient ischemic attack migraine migraine with symptoms (migraine which changed the consciousness) inflammation or infection Acute demyelinating encephalomyelitis, encephalitis, brain abscess, meningitis, Meningoenze phalitis, CNS vasculitis Seizure disorders Nichtkonvulsiver status epilepticus, postictal state trauma subdural hematoma, traumatic head injury tumor Meningeal carcinomatosis, primary or metastatic brain tumor non Euro Logical causes Drug therapy anticholinergics, antiemetics, antihistamines (eg. As diphenhydramine), antihypertensives, antimicrobials, antipsychotics, benzodiazepines, cardiovascular drugs (often beta blockers), cimetidine, digoxin, dopamine agonists, recreational drugs, hypnotics, corticosteroids, muscle relaxants, NSAIDs, opioids, sedatives, antispasmodics, tricyclic antidepressants Endocrine Disorders Cushing’s syndrome, hyperparathyroidism, hyperthyroidism, hypothyroidism, insufficiency of the adrenal or pituitary gland hematologic disorders hyperviscosity syndrome, leukemic blast crisis, polycythemia, thrombocytosis infections fever, urinary tract infections, pneumonia, sepsis, systemic endemic infection, injury, burns, injuries due to electric current, fat embolism, heat stroke, hypothermia metabolic disorders fluid and electrolyte abnormalities (eg. B. dehydration, hypercalcemia, hypernatremia, hypocalcemia, hyponatremia, hypomagnesemia), hepatic or uremic encephalopathy, hyperglycemia, hyperosmolality, hyperthermia, hypoglycemia, hypoxia, acid-base disturbances, Wernicke encephalopathy, vascular and circulatory-related disorders anemia, heart failure, cardiac arrhythmia, hypoperfusion states, shock vitamin D deficiency thiamine, vitamin B12 deficiency withdrawal syndrome alcohol, barbiturates, benzodiazepines, opioids Other Ursac hen urinary retention, hypertensive encephalopathy, fecal impaction, a long stay in an ICU, liver failure, postoperative conditions, mental disorders, sleep deprivation, sensory deprivation, toxins that attack the central nervous system, change of the environment Pathophysiology mechanisms are not fully understood but may include the following Reversible impairment of cerebral oxidative metabolism Several neurotransmitter abnormalities the production of cytokines stress of any kind increases the sympathetic tone and reduces the parasympathetic tone, whereby the cholinergic function is impeded and thereby contributes to delirium. Just Older particularly sensitive to reduced cholinergic neurotransmission, which increases their risk for delirium. Whatever the cause of delirium, there is a disturbance of the cerebral hemispheres or arousal mechanisms of the thalamus and the “ascending reticular activating system” (ARAS) in the brainstem. Symptoms and complaints Delirium is primarily characterized by difficulty in focusing, maintaining or changing the attention (inattention). The level of consciousness fluctuates, patients are disoriented to time and sometimes to place and person. You can have hallucinations, delusions and paranoia. Confusion regarding everyday events and the daily routine is common, as changes in personality and emotion. The thinking is disorganized, the language is often disrupted, with a distinctive mumble, speed, neologisms, aphasic errors, or chaotic speech patterns. The symptoms of delirium fluctuate over minutes to hours; they can go during the day and worsen at night. Other symptoms also inappropriate behavior, fearfulness and paranoia may belong. Patients can irritable, agitated, hyperactive and monitored, or they can be quiet, withdrawn and lethargic. Very old people with delirium tend to be quiet and withdraw-these changes can possibly be misinterpreted as depression. Some patients vary between two states. Most sleep patterns and eating habits are massively disrupted. Because of the many cognitive impairment, the disease insight is low and disturbed the judgment. Other symptoms and complaints may be present depending on the cause. Diagnostic survey of psychopathological symptoms standard diagnostic criteria for confirmation of delirium Thorough history Targeted physical examination, and selected tests to determine the cause Delirium is often overlooked, especially in older patients by doctors. Clinicians should in an elderly patient, who impressed with a memory impairment or attention, pull delirium into consideration. Tips and risks Pull both delirium and dementia considered in elderly patients with impaired memory. Collection of psychopathological symptoms patients with any evidence of cognitive impairment require a formal examination of her mental status (examination of mental status). First, attention is assessed. Simple tests include immediate repetition of the names of three objects, the Digit Span (ability to 7 digits forward and 5 digits backwards to repeat) and calling the weekdays forward and backward. Inattention (the patient does not take instructions or other information note) must come from a poor short-term memory (the patient receives information, but she forgets very quickly) can be distinguished. Further cognitive tests in patients who can not receive the information useless. After the initial examination standardized diagnostic criteria such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or the Confusion Assessment Method (CAM) can be used. The following characteristics are required for the diagnosis of delirium according to DSM-5 criteria: (. To focus, for example, issues or to follow what is being said) disorders of attention and consciousness (ie, reduced orientation in the area), the disturbance develops over a short period of time (over hours to days) and tends to fluctuate during the day. Acute change in cognition (eg. As deficits of memory, language, perception, thinking) Moreover, evidence from the history, physical examination and / or laboratory tests must indicate that the disorder is caused by a medical disorder, a substance (including drugs or toxins), or substance withdrawal. CAM uses the following criteria: Altered level of consciousness (. Eg monitoring, lethargic, stuporous, comatose) or thought disorders (eg, licentious, irrelevant conversation, illogical flow of ideas.) History The history is collected by interviewing family members, caregivers and friends. You can determine if the mental changes are new and different from a possible underlying disease (see table: Differences Between Delirium and Dementia *). The history helps to distinguish a psychological disorder from a delirium. cause mental disorders, unlike delirium, almost never an inattention or fluctuating consciousness, and the beginning of mental disorders is nearly always subacute. “Sundowning” (behavioral deterioration in the evenings), which is common in institutionalized patients with dementia can be difficult to distinguish; a new symptomatic deterioration should be held until the contrary is proved for delirium. The history should also include the use of alcohol, all illegal drugs, over the counter and prescription drugs; specifically of overdose should be asked with central nervous system effects and for supplements, interruptions or dose changes in medication, including for drugs.. Food supplements (. Eg herbal products) should also be included werden.Körperliche investigation An investigation should be, especially in patients who do not cooperate fully concentrate on the following points: vital signs Hydrierungsstatus Potential sources of infection skin and head and neck Neurological examination The findings may provide clues give to the cause, as in the following: fever, neck stiffness or Kernig and brudzi?ski’s sign indicate a CNS infection. Tremor and myoclonus indicate uremia, liver failure, intoxication or some electrolyte disorders (eg. B. hypocalcemia, hypomagnesemia). Ophthalmoplegia and ataxia speak for a Wernicke-Korsakoff syndrome. Focal neurological abnormalities (eg. As cranial nerve palsies, motor or sensory deficits) or papilledema suggest a structural CNS lesion. Scalp or facial injuries, bruising, swelling and other evidence of head injury suggest a traumatic brain injury. Tests The tests usually include: CT or MRI tests for suspected infection (. Eg blood count, blood cultures, chest X-ray, urinalysis) Review for hypoxia (pulse oximetry or arterial blood gases) Measurement of electrolytes, BUN, creatinine, plasma glucose and blood levels of drugs that are suspected to have toxic effects A drug screen urine in case of unclear diagnosis may be further investigation: determination of liver function tests, serum calcium and albumin, thyroid-stimulating hormone (TSH), vitamin B12, erythrocyte sedimentation rate, and antinuclear antibodies (ANA ) and a test for syphilis (z. B. Rapid plasma reagin test [RPR] or Venereal Disease Research Laboratory [VDRL]). If the diagnosis is still unclear, the tests may include a cerebrospinal fluid (especially to rule out meningitis, encephalitis or subarachnoid hemorrhage), a serum ammonia Bestimmunung and testing for heavy metals. If nichtkonvulsive seizure activity, including status epilepticus, is suspected (accepted by discrete motor tics, automatism or the presence of a stable, but not very eye-catching image of the confusion and dizziness), an EEG recording should be performed. Prognosis The morbidity and mortality rates are increased in patients who have delirium and are hospitalized or who develop delirium during hospitalization; 35-40% of inpatient Delirpatienten die within a year. These prices may be high, in part because such patients generally tend to be older and have other serious diseases. Delirium, which is due to certain causes (eg. As hypoglycemia, drug or alcohol intoxication, infection, iatrogenic factors, drug toxicity, electrolyte imbalance) regresses rapidly during treatment. However, the clinical recovery may slow run (over days or even weeks and months), especially in the elderly, which can result in longer hospital stays, a greater risk and increased severity of complications, increased costs and a long-term disability. Some patients never recover fully from a delirium. Up to 2 years after the cause of delirium the risk for cognitive and functional deterioration, institutionalization and death is increased. Treatment correction of the cause and correction of increasing factors Supportive care command of agitation correcting the cause (z. B. infection treatment, administration of fluids and electrolytes, rehydration) and removal of the reinforcing factors (z. B. discontinuation of medication) can be used to decrease the cause delirium. Nutrient deficiency (eg. As of thiamine or vitamin B12) should be balanced for good nutrition and hydration must be ensured. General measures The environment should be consistent, quiet and well lit, with visual guidance for the patient (eg. As calendars, clocks, family photos). A frequent reorientation and reinsurance by the caregivers or family members is also helpful. Sensory deficits should be minimized (z. B. also to use replacement batteries in hearing aids, the request of the patient, his eyeglasses and hearing aids). The treatment approach should be interdisciplinary (with doctor, physiotherapists, occupational therapists, nurses and social workers); it should include strategies to increase the mobility and range of motion, the treatment of pain and discomfort, skin lesions prevent, improve incontinence and minimize the risk of aspiration. Agitation can greatly disturb both the well-being of the patient and the nurses and hospital staff. A consistent as possible simplification of drug therapy and the avoidance of i.v. additions, urinary catheters and fixation (v. A. In the long-term care provision) can help prevent exacerbation of agitation and reduce the risk of injury. However, a fix in certain circumstances may be necessary to protect the patient from self-injury or foreign injury. Fixing should be created only by personnel who are trained in dealing with these materials; they should at least every 2 hours to be solved in order to prevent injuries and be canceled as soon as possible. The use of seat guards for continuous observation can help avoid the need for fixation. to declare family members what delirium actually means, can help them cope with it. It should be told that delirium is usually reversible, that cognitive deficits but often (until weeks or months after the fall of the acute illness abklingen.Arzneimittel drugs, typically low-dose haloperidol 0.5-1.0 mg po , IV or IM once, then repeated every 1-2 hours as needed), agitation or psychotic symptoms can reduce; occasionally are much higher doses required. (Editor’s note: The iv administration of haloperidol is not recommended due to the risk of serious cardiac arrhythmias in Germany Should a risk-benefit assessment in individual cases for IV use talking is a continuous ECG monitoring is required..) However, drugs do not solve the underlying problem and can extend delirium or worsen. Atypical antipsychotics (the second generation antipsychotics) (z. B. Risperidone h 0.5-3 mg PO every 12, olanzapine 2.5-15 mg / day po, Quetiapine 25 to 200 mg PO every 12 h) may be preferred because they cause fewer extrapyramidal side effects; However, the long-term use may increase in patients with dementia, the risk of suffering a stroke and die. These medicines are usually not i.v. or i.m. administered. Benzodiazepines (z. B. lorazepam 0.5-1.0 mg p.o. or i.v. once, then repeated every 1-2 hours as needed) are the treatment of choice for delirium by alcohol or benzodiazepine withdrawal. (Editor’s note: The German guidelines recommend at a Alkoholentzugsdelir clomethiazole or diazepam or lorazepam (4 to 6 times a day 1 mg) or chlordiazepoxide). You onset of action is rapid (5 min after parenteral administration) than that of antipsychotic agents. Benzodiazepines should be avoided if delirium is due to other disorders, as exacerbated by these drugs confusion and sedation. Since prevention deteriorated significantly by a delirium, the prognosis for inpatients, emphasis should be placed on prevention. Hospital staff should be trained in measures to maintain the orientation, mobility and cognition and to ensure sleep, good nutrition and hydration and adequate pain relief, especially in the elderly. Family members can be encouraged to assist in this action. The number and dose of drugs should be reduced where possible. Conclusion Delirium, which is very common in hospitalized elderly patients is often caused by drugs, dehydration and infections (eg. As urinary tract infection), but it can also have many other causes. Pull in elderly patients delirium into consideration, especially those that show memory problems or inattention. The history and raised with family members, caregivers and friends to check in mental status are the key to recognizing a delirium. Assess patients with delirium thoroughly for possible neurological and systemic causes and triggers. Do a thorough Medi Kamen anamnesis and stop all potentially contributing to medication. Approximately 35-40% of hospitalized patients with delirium die within a year. Treat the cause of delirium and make supportive care available, including sedation, if necessary.

Health Life Media Team

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