Article by Dr Manasa S, B.A.M.S
Introduction of Delirium
Delirium is a swift and unsettling form of mental confusion that impairs your ability to concentrate and stay aware. It arises when there’s a widespread disturbance in brain function, often triggered by a combination of factors. This condition is frequently encountered in medical environments, such as extended hospital stays or within long-term care facilities.
Individuals experiencing delirium often exhibit behaviours and characteristics starkly different from their usual selves. Loved ones may find themselves remarking, “That’s not the person I know.”
In the past, delirium was often overlooked as a minor issue, but contemporary understanding recognizes its severity and the need for proactive identification and prevention.
Studies suggest it affects between 18% and 35% of hospitalized individuals and up to 60% of those in intensive care. Yet, it’s suspected that many cases go undetected, with estimates indicating that anywhere from one-third to two-thirds of instances remain undiagnosed.
While more common in older adults, particularly those over 65, delirium can occur across all age groups under certain circumstances, including children, teenagers, and young adults. Understanding delirium’s reach and impact is crucial for effective management and care.
Alternative terminologies for delirium
– Sundowning
– Encephalopathy
– Pleasantly confused
– Altered mantal status
– Intensive care unit [ICU] or post-surgery psychosis
Common causes of delirium
The ability of both body and mind to maintain functionality or recuperate from challenges relies significantly on one’s functional capacity. However, the presence of risk factors diminishes this reserve. Elevated stressors and risk factors exacerbate susceptibility to delirium. When stressors surpass an individual’s functional reserve capacity, whether independently or due to heightened vulnerability from risk factors, the likelihood of delirium onset increases.
Stressors (Causes and Contributing Factors)
a. Conditions
– People with dementia have a higher risk of developing delirium.
– Conditions such as cancer, infections (including HIV, pneumonia, or COVID-19), sepsis, or stroke increase the likelihood of delirium.
– Individuals with recent bone fractures are also at a heightened risk for delirium.
b. Procedures and Treatments
– Major surgery, especially unplanned or emergency surgery, significantly increases the risk of delirium.
– Intubation or mechanical ventilation can exacerbate the likelihood of delirium.
c. Mobility
– Prolonged periods of immobility, particularly lying down, can impact brain function.
– Engaging in physical therapy and regular movement reduces the risk of delirium and shortens its duration if it occurs.
d. Tethers
– Intravenous lines, Foley catheters, oxygen tubes, or physical restraints limit mobility and contribute to delirium.
– Even minor devices like heart monitoring sensor patches can act as tethers.
e. Medications
– Certain medications, even when used as prescribed, can increase the risk of delirium.
– Polypharmacy, defined as taking more than five medications concurrently, heightens the risk.
f. Nonmedical Drug Use
– Misuse of prescription medications or nonmedical drug use can induce delirium.
g. Environment
– Disruption of natural lighting or sound can disrupt the sleep / wake cycle and increase the risk of delirium.
h. Pain Management
– Poorly managed or untreated pain contributes to the risk of delirium.
i. Stimulation
– Lack of sensory input, including hearing and vision impairments, increases the likelihood of delirium.
j. End-of-Life Factors
– Delirium can occur during the end stages of life, particularly in individuals receiving palliative care.
k. Social Isolation
– Separation from loved ones exacerbates delirium, while social interaction can mitigate its effects.
Pathophysiology of delirium
Pathophysiology
Increased Age – Age-related changes lead to decreased physiological reserve, making older adults more vulnerable to stress and illness.
Neuroinflammation – Inflammatory insults can disrupt the blood-brain barrier, leading to inflammation and neuronal damage.
Reactive Oxidation Species – Cellular damage caused by reactive oxygen species affects the central nervous system, contributing to delirium.
Circadian Rhythm Dysregulation – Disrupted sleep-wake cycles and melatonin secretion affect various brain functions.
Neurotransmitter Imbalance – Changes in acetylcholine and dopamine levels impact brain function.
Neuroendocrine – Increased glucocorticoid release during stress affects neuronal vulnerability and gene regulation.
Risk Factors
Age – Individuals aged 65 and older are at increased risk of delirium due to age-related changes.
Dementia and Degenerative Brain Diseases – Existing conditions affecting brain function elevate the risk of delirium.
Chronic Physical Conditions – Conditions like heart disease and COPD strain the body, increasing susceptibility to delirium.
Mood Disorders – History of mood disorders, particularly depression, heightens the risk of delirium.
Vision and Hearing Loss – Impairment of sensory functions reduces the brain’s ability to process external cues, increasing susceptibility to delirium.
Alcohol and Nonmedical Drug Use – Misuse of opioids and benzodiazepines significantly raises the risk of delirium.
Previous History of Delirium – Individuals with a prior episode of delirium are at increased risk of recurrence.
Frailty – Increased vulnerability to illness or injury, especially in older adults, amplifies the risk of delirium.
Symptoms of delirium
Symptoms Onset and Patterns
– Symptoms start over hours or days.
– Usually linked with a medical problem.
– Symptoms fluctuate during the day, and may disappear for a while.
– Worse at night and in unfamiliar settings like hospitals.
Primary Symptoms
– Reduced Awareness
– Trouble focusing or changing topics.
– Getting stuck on ideas.
– Easily distracted or withdrawn.
Poor Thinking Skills
– Poor memory, forgetting recent events.
– Confusion about location or identity.
– Trouble with speech or understanding.
Behaviour and Emotional Changes
– Anxiety, fear, or distrust.
– Depression or sudden anger.
– Sense of elation or emotional numbness.
– Quick mood swings or personality changes.
– Hallucinations or restlessness.
– Vocalizations or quiet withdrawal.
– Slowed movement or agitation.
– Changes in sleep patterns, like a reversed sleep-wake cycle.
Types of Delirium
Hyperactive Delirium
– Restlessness, pacing.
– Anxiety, mood swings, hallucinations.
– Resistance to care.
Hypoactive Delirium
– Reduced activity, sluggishness.
– Seeming dazed, lack of interaction.
– Reduction in facial expressions and speaking
– Apathy and a lack of interest in what is happening around
– Loss of interest or participation in self-care.
Mixed Delirium
– Alternates between restlessness and sluggishness.
What are the common complications of Delirium?
Delirium results in extensive disturbance in brain activity, potentially causing various complications. These complications span from transient and minor to enduring and severe.
Key complications to be aware of –
a. Onset of new dementia or exacerbation of pre-existing dementia.
b. Incidents of falls and resultant traumatic injuries.
c. Persistent cognitive impairment or lasting brain function issues.
d. Decline in self-care abilities, resulting in a loss of independence.
e. Development of mental health conditions such as depression and post-traumatic stress disorder (PTSD).
f. Diminished physical capabilities.
How is delirium diagnosed?
Delirium is diagnosed on the basis of history and presenting complaints.
The Confusion Assessment Method is used by most healthcare professionals.
The following investigations are carried out to check the underlying causes
– Blood tests
– Chest X-ray
– Electrocardiogram
– Urine tests
– Bladder imaging
Management and treatment of delirium
Medications
Treatment depends on the cause of delirium.
Medications may be prescribed to address the underlying issue:
– Inhalers for breathing issues like severe asthma.
– Antibiotics for bacterial infections.
– Discontinuation of certain medications causing delirium.
– Medications for managing substance withdrawal symptoms.
– Antipsychotic medications for severe hyperactive delirium symptoms if necessary.
Supportive Care
– Creating a calm environment reduces stress and aids recovery
– Follow a clear daily routine.
– Maintain regular eating and drinking habits.
– Keep visible clocks and calendars for orientation.
– Ensure good sleep habits.
– Engage in safe physical activities.
– Regularly use glasses and hearing aids if needed.
Tips for caregivers
– Speak calmly and use short sentences.
– Provide reassurance.
– Avoid unnecessary changes in surroundings.
– Share familiar objects like photos.
Counselling
– Counselling can help anchor thoughts and feelings during disorientation.
– Used as treatment for substance-induced delirium to aid in abstaining from substances.
– Provides a safe space to discuss thoughts and feelings, promoting comfort and recovery.
Can delirium be prevented?
Prevention Techniques by Healthcare Providers
– Conduct regular delirium assessments to catch warning signs early.
– Prioritize natural lighting to maintain the body’s natural rhythm.
– Address vision and hearing problems with glasses and hearing aids.
– Encourage early mobility under medical guidance to lower delirium risk.
– Minimize tether effects such as IV lines and restraints.
– Engage in mental exercises with calendars and clocks.
Contributions of Loved Ones in Delirium Prevention
– Visit and engage in social interactions following facility guidelines.
– Engage in meaningful conversations beyond small talk.
– Decorate surroundings with familiar objects and photos.
– Participate in activities together like games or watching TV.
Prognosis and Self-Care
– Delirium disrupts awareness, memory, judgment, and self-care.
– Delirium may have long-lasting effects even with treatment.
– Higher levels of care are required during severe delirium.
– Post-delirium, lingering effects may persist, necessitating ongoing medical care and assistance.
Study – Delirium is associated with short- and long-term health outcomes in medically admitted patients – A Prospective Study.
Study – Delirium Research in India – A Systematic Review
Delirium: Ayurveda Understanding
Delirium has been popularly compared to a condition called ‘pralapa’ mentioned in Ayurveda treatises. But this term has been mentioned but nor explained. Pralapa actually means irrelevant talking along with irrelevant actions. This is predominantly caused by vata. Pralapa is one of the symptoms of vata vriddhi – pathological increase of vata.
It is said to predominantly manifest in old aged persons and due to cellular / tissue damage and the symptoms are prominent during night. Both flavors increase vata.
Treatment of delirium mainly includes all ‘vata balancing’ measures. This includes vata balancing foods, lifestyle activities and practices, therapies, behaviours and medicines. One should properly follow the seasonal regimen of ‘vata aggravating’ seasons.
Delirium is also related to imbalances of mind. The mind and its functions are also monitored by vata. Imbalances in vata can cause imbalances in the mind. Therefore therapies, medicines, diet and all measures which calm the mind should also be considered, which includes dhee – intellectual training and counselling, dhairya – instilling courage and providing care and love and atmadi vijnanam – making the person realize the importance of self.
Related Reading – ‘Delirium – Ayurveda Understanding’
