Delirium history and symptoms: Difference between revisions
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{{Delirium}} | {{Delirium}} | ||
{{CMG}}; {{AE}} [[User:Vishal Khurana|Vishal Khurana]], M.B.B.S., M.D. [mailto:vishdoc24@gmail.com] | {{CMG}}; {{AE}} {{Sara.Zand}} {{PB}}; [[User:Vishal Khurana|Vishal Khurana]], M.B.B.S., M.D. [mailto:vishdoc24@gmail.com] | ||
==Overview== | ==Overview== | ||
[[Delirium]] causes impairment in functions, [[sleep-wake cycle]] and also has a behavioral component. Common [[symptoms]] associated with [[delirium]] include altered [[level of consciousness]], [[inattention]], [[disorientation]], [[hallucination]], [[delusions]], [[agitation]], inappropriate [[speech]], [[sleep]]–[[wake]] disturbances, [[ Symptom]] fluctuation, [[emotional disturbance]]. Subclinical [[delirium]] or prodromal [[delirium]] may precede by 1 to 3 days prior to an overt [[delirium]], which presents as [[restlessness]], [[anxiety]], irritability, [[distractibility]], [[sleep disturbance]] with less severe [[cognitive]] impairment in comparison to [[delirium]]. | |||
== | ==Symptoms== | ||
Common [[symptoms]] associated with [[delirium]] include: | |||
:*Altered [[level of consciousness]] | |||
* | :* [[Inattention]] | ||
* | :* [[Disorientation]] | ||
* | :* [[Hallucination]], [[delusions]] | ||
:* [[Agitation]] | |||
* | :* Inappropriate [[speech]] | ||
=== | :* [[Sleep]]–[[wake]] disturbances (daytime [[sleepiness]], nighttime [[agitation]], disturbances in [[sleep]] continuity, complete reversal of the night-day [[sleep]]-[[wake]] cycle, and fragmentation of the [[circadian]] [[sleep-wake]] pattern) | ||
* | :*[[ Symptom]] fluctuation | ||
:*[[Emotional disturbance]] ([[anxiety]], [[fear]], [[depression]], [[irritability]], [[anger]], [[euphoria]], [[apathy]], [[affective lability]], rapid and unpredictable shifts from one [[emotional]] state to another | |||
*Subclinical [[delirium]] or prodromal [[delirium]] may precede by 1 to 3 days prior to an overt [[delirium]], which presents as [[restlessness]], [[anxiety]], irritability, [[distractibility]], [[sleep disturbance]] with less severe [[cognitive]] impairment in comparison to [[delirium]]. <ref name="SerafimSoares2017">{{cite journal|last1=Serafim|first1=Rodrigo B.|last2=Soares|first2=Marcio|last3=Bozza|first3=Fernando A.|last4=Lapa e Silva|first4=José R.|last5=Dal-Pizzol|first5=Felipe|last6=Paulino|first6=Maria Carolina|last7=Povoa|first7=Pedro|last8=Salluh|first8=Jorge I. F.|title=Outcomes of subsyndromal delirium in ICU: a systematic review and meta-analysis|journal=Critical Care|volume=21|issue=1|year=2017|issn=1364-8535|doi=10.1186/s13054-017-1765-3}}</ref> | |||
* [[Seizures]] may occur in [[delirium]], particularly among [[patients]] with [[alcohol]] or withdrawal, [[cocaine]] intoxication, [[head trauma]], [[hypoglycemia]], [[strokes]], or extensive burns.<ref name="www.ncbi.nlm.nih.gov">{{Cite web | last = | first = | title = Practice guideline for the treatment of pati... [Am J Psychiatry. 1999] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/10327941 | publisher = | date = | accessdate = }}</ref> | |||
== | ==[[History]]== | ||
* | * Simple [[cognitive]] testing such as Mini-mental Scale examination should be administered in all [[elderly]] [[patients]] admitted to hospital. However these test can not differentiate [[delirium]] from other [[cognitive]] disorders.<ref name="MitchellShukla2014">{{cite journal|last1=Mitchell|first1=Alex J.|last2=Shukla|first2=Deepak|last3=Ajumal|first3=Hafsa A.|last4=Stubbs|first4=Brendon|last5=Tahir|first5=Tayyeb A.|title=The Mini-Mental State Examination as a diagnostic and screening test for delirium: systematic review and meta-analysis|journal=General Hospital Psychiatry|volume=36|issue=6|year=2014|pages=627–633|issn=01638343|doi=10.1016/j.genhosppsych.2014.09.003}}</ref> | ||
* | * Serial measurement maybe helpful to detect new-onset [[delirium]]. | ||
* | * [[History]] from [[relatives]] is often useful to determine the onset, progress, and duration of [[delirium]]. [[Patients]] with [[confusional]] states may not provide an accurate history. | ||
* A detailed history must include the following: | |||
# History of prescribed and non‑prescribed [[medicines]] | |||
# [[History]] of [[alcohol]] and other recreational [[drugs]] | |||
# [[History]] of activities of daily living such as payment of bills | |||
# Onset, progression and duration of [[confusion]] | |||
# Previous [[history]] of acute or chronic [[confusion]] | |||
# [[Social]] circumstances and [[support]] | |||
# Any other co-morbid [[illness]] such as [[epilepsy]] | |||
# Symptoms suggestive of underlying cause ([[infection]]) | |||
# [[Motor]] or [[sensory]] deficits | |||
# Aids used ( [[hearing aid]], [[glasses]]) | |||
==Commonly Co-Occurring Mental Symptoms, with a note on Severity== | |||
* [[Delirium]] may occur in very many grades of severity, all symptoms may occur with varying degrees of intensity. <ref name="pmid27975002">{{cite journal |vauthors=Lippmann S, Perugula ML |title=Delirium or Dementia? |journal=Innov Clin Neurosci |volume=13 |issue=9-10 |pages=56–57 |date=2016 |pmid=27975002 |pmc=5141598 |doi= |url=}}</ref> | |||
* A mild [[disability]] to focus [[attention]] may result in only a disability in solving the most complex [[problems]]. | |||
* However, as [[delirium]] becomes more severe, it disrupts other [[mental]] functions, and maybe so severe that it borders on [[unconsciousness]] or a [[vegetative]] state. | |||
* In the latter state, a [[person]] may be [[awake]] and [[immediately]] [[aware]] and [[responsive]] to many stimuli, and capable of [[coordinated]] movements, but unable to perform any [[meaningful]] [[mental]] processing task at all. | |||
===Inability to [[Focus]] [[Attention]], [[Confusion]] and [[Disorientation]]=== | |||
*The [[delirium]]-sufferer loses the capacity for clear and [[coherent] [[thought]].<ref name="ThomLevy-Carrick2019">{{cite journal|last1=Thom|first1=Robyn P.|last2=Levy-Carrick|first2=Nomi C.|last3=Bui|first3=Melissa|last4=Silbersweig|first4=David|title=Delirium|journal=American Journal of Psychiatry|volume=176|issue=10|year=2019|pages=785–793|issn=0002-953X|doi=10.1176/appi.ajp.2018.18070893}}</ref> | |||
* This may be apparent in disorganized or [[incoherent]] [[speech]], the [[inability]] to [[concentrate]] ([[focus attention]]), or in a lack of any goal-directed [[thinking]]. | |||
* [[Disorientation]] (another symptom of [[confusion]], and usually a more severe one) is described as the loss of [[awareness]] of the surroundings, environment, and context in which the person exists. | |||
* [[Disorientation]] may occur in [[time]] (not knowing what time of day, day of the week, month, [[season]] or year it is), [[place]] (not knowing where one is) or [[person] (not knowing who one is). | |||
* [[ Cognitive]] function may be impaired enough to make [[medical]] criteria for [[delirium]], even if [[orientation]] is preserved. | |||
* A [[patient]] who is fully [[aware]] of where they are and who they are, but cannot think because they cannot concentrate, maybe medically [[delirious]]. | |||
* The state of [[delirium]] most familiar to the average [[person]] is that which occurs from extremes in [[ pain]], lack of [[sleep]], or [[emotional]] shock. | |||
* Because most high-level mental skills are required for [[problem-solving]], including the ability to focus [[attention]], this ability also suffers in [[delirium]]. | |||
* However, this is a secondary phenomenon, since [[problem-solving]] involves many sub-skills and basic [[mental]] abilities, any of which may be impaired in a [[delirious]] patient. | |||
===[[Memory]] Formation Disturbance=== | |||
* Impairments of [[cognition]] may include a temporary reduction in the ability to form [[short-term]] or [[long-term]] [[memory]]. | |||
* Difficult [[short-term memory]] tasks inability to repeat a phone number may be continuously disrupted during a [[delirium]], but easier [[short-term memory]] tasks like repeating single words, or [[remembering]] [[simple questions]] long enough to give an answer, may not be impaired. | |||
* Reduction in the formation of new [[long-term memory]] (which by definition survive the withdrawal of [[attention]]), is common in [[delirium]] because the initial formation of (new) long-term memories generally requires an even higher degree of [[attention]], than do [[short-term memory]] tasks. | |||
* Since older [[memories]] are retained without the need of [[concentration]], previously formed [[long-term memories]] ( those formed before the period of [[delirium]]) are usually preserved in all but the most severe cases of [[delirium]] (and when destroyed, are destroyed by the underlying [[brain]] pathology, not the [[delirious]] state per se). | |||
===Abnormalities of Awareness and Affect=== | |||
* [[Hallucination]]s (perceived sensory experience with the lack of an external source) or [[distortions]] of reality may occur in [[delirium]]. | |||
* Commonly these are [[visual]] distortions, and can take the form of masses of small [[crawling]] creatures (particularly common in [[delirium tremens]], caused by severe [[alcohol]] withdrawal) or distortions in size or intensity of the surrounding [[environment]]. | |||
* Strange [[belief]]s may also be held during a [[delirious]] state, but these are not considered fixed [[delusion]]s in the clinical sense as they are considered too short-lived (they are ''temporary'' [[delusions]]). | |||
*In some cases [[patients]] may be left with false or [[delusional]] [[memories]] after [[delirium]], basing their [[memories]] on the confused [[thinking]] or [[sensory]] distortion which occurred during the episode of [[delirium]]. | |||
* Other instances would be the inability to distinguish [[reality]] from [[dreams]]. | |||
* Abnormalities of [[ affect]] may include many [[distortions]] to [[perceived]] or [[communicated]] [[emotion]]al states. | |||
* [[Emotional]] states may also [[fluctuate]], so that a [[delirious]] person may rapidly change between, for example, [[terror]], [[sadness]], and [[jocularity]]. | |||
===Abnormalities of | |||
[[Hallucination]]s (perceived sensory experience with the lack of an external source) or distortions of reality may occur in delirium. Commonly these are visual distortions, and can take the form of masses of small crawling creatures (particularly common in [[delirium tremens]], caused by severe alcohol withdrawal) | |||
Strange [[belief]]s may also be held during a delirious state, but these are not considered fixed [[delusion]]s in the clinical sense as they are considered too short-lived ( | |||
Abnormalities of affect | |||
==References== | ==References== | ||
Latest revision as of 11:51, 22 April 2021
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Pratik Bahekar, MBBS [3]; Vishal Khurana, M.B.B.S., M.D. [4]
Overview
Delirium causes impairment in functions, sleep-wake cycle and also has a behavioral component. Common symptoms associated with delirium include altered level of consciousness, inattention, disorientation, hallucination, delusions, agitation, inappropriate speech, sleep–wake disturbances, Symptom fluctuation, emotional disturbance. Subclinical delirium or prodromal delirium may precede by 1 to 3 days prior to an overt delirium, which presents as restlessness, anxiety, irritability, distractibility, sleep disturbance with less severe cognitive impairment in comparison to delirium.
Symptoms
Common symptoms associated with delirium include:
- Altered level of consciousness
- Inattention
- Disorientation
- Hallucination, delusions
- Agitation
- Inappropriate speech
- Sleep–wake disturbances (daytime sleepiness, nighttime agitation, disturbances in sleep continuity, complete reversal of the night-day sleep-wake cycle, and fragmentation of the circadian sleep-wake pattern)
- Symptom fluctuation
- Emotional disturbance (anxiety, fear, depression, irritability, anger, euphoria, apathy, affective lability, rapid and unpredictable shifts from one emotional state to another
- Subclinical delirium or prodromal delirium may precede by 1 to 3 days prior to an overt delirium, which presents as restlessness, anxiety, irritability, distractibility, sleep disturbance with less severe cognitive impairment in comparison to delirium. [1]
- Seizures may occur in delirium, particularly among patients with alcohol or withdrawal, cocaine intoxication, head trauma, hypoglycemia, strokes, or extensive burns.[2]
History
- Simple cognitive testing such as Mini-mental Scale examination should be administered in all elderly patients admitted to hospital. However these test can not differentiate delirium from other cognitive disorders.[3]
- Serial measurement maybe helpful to detect new-onset delirium.
- History from relatives is often useful to determine the onset, progress, and duration of delirium. Patients with confusional states may not provide an accurate history.
- A detailed history must include the following:
- History of prescribed and non‑prescribed medicines
- History of alcohol and other recreational drugs
- History of activities of daily living such as payment of bills
- Onset, progression and duration of confusion
- Previous history of acute or chronic confusion
- Social circumstances and support
- Any other co-morbid illness such as epilepsy
- Symptoms suggestive of underlying cause (infection)
- Motor or sensory deficits
- Aids used ( hearing aid, glasses)
Commonly Co-Occurring Mental Symptoms, with a note on Severity
- Delirium may occur in very many grades of severity, all symptoms may occur with varying degrees of intensity. [4]
- A mild disability to focus attention may result in only a disability in solving the most complex problems.
- However, as delirium becomes more severe, it disrupts other mental functions, and maybe so severe that it borders on unconsciousness or a vegetative state.
- In the latter state, a person may be awake and immediately aware and responsive to many stimuli, and capable of coordinated movements, but unable to perform any meaningful mental processing task at all.
Inability to Focus Attention, Confusion and Disorientation
- The delirium-sufferer loses the capacity for clear and [[coherent] thought.[5]
- This may be apparent in disorganized or incoherent speech, the inability to concentrate (focus attention), or in a lack of any goal-directed thinking.
- Disorientation (another symptom of confusion, and usually a more severe one) is described as the loss of awareness of the surroundings, environment, and context in which the person exists.
- Disorientation may occur in time (not knowing what time of day, day of the week, month, season or year it is), place (not knowing where one is) or [[person] (not knowing who one is).
- Cognitive function may be impaired enough to make medical criteria for delirium, even if orientation is preserved.
- A patient who is fully aware of where they are and who they are, but cannot think because they cannot concentrate, maybe medically delirious.
- The state of delirium most familiar to the average person is that which occurs from extremes in pain, lack of sleep, or emotional shock.
- Because most high-level mental skills are required for problem-solving, including the ability to focus attention, this ability also suffers in delirium.
- However, this is a secondary phenomenon, since problem-solving involves many sub-skills and basic mental abilities, any of which may be impaired in a delirious patient.
Memory Formation Disturbance
- Impairments of cognition may include a temporary reduction in the ability to form short-term or long-term memory.
- Difficult short-term memory tasks inability to repeat a phone number may be continuously disrupted during a delirium, but easier short-term memory tasks like repeating single words, or remembering simple questions long enough to give an answer, may not be impaired.
- Reduction in the formation of new long-term memory (which by definition survive the withdrawal of attention), is common in delirium because the initial formation of (new) long-term memories generally requires an even higher degree of attention, than do short-term memory tasks.
- Since older memories are retained without the need of concentration, previously formed long-term memories ( those formed before the period of delirium) are usually preserved in all but the most severe cases of delirium (and when destroyed, are destroyed by the underlying brain pathology, not the delirious state per se).
Abnormalities of Awareness and Affect
- Hallucinations (perceived sensory experience with the lack of an external source) or distortions of reality may occur in delirium.
- Commonly these are visual distortions, and can take the form of masses of small crawling creatures (particularly common in delirium tremens, caused by severe alcohol withdrawal) or distortions in size or intensity of the surrounding environment.
- Strange beliefs may also be held during a delirious state, but these are not considered fixed delusions in the clinical sense as they are considered too short-lived (they are temporary delusions).
- In some cases patients may be left with false or delusional memories after delirium, basing their memories on the confused thinking or sensory distortion which occurred during the episode of delirium.
- Other instances would be the inability to distinguish reality from dreams.
- Abnormalities of affect may include many distortions to perceived or communicated emotional states.
- Emotional states may also fluctuate, so that a delirious person may rapidly change between, for example, terror, sadness, and jocularity.
References
- ↑ Serafim, Rodrigo B.; Soares, Marcio; Bozza, Fernando A.; Lapa e Silva, José R.; Dal-Pizzol, Felipe; Paulino, Maria Carolina; Povoa, Pedro; Salluh, Jorge I. F. (2017). "Outcomes of subsyndromal delirium in ICU: a systematic review and meta-analysis". Critical Care. 21 (1). doi:10.1186/s13054-017-1765-3. ISSN 1364-8535.
- ↑ "Practice guideline for the treatment of pati... [Am J Psychiatry. 1999] - PubMed - NCBI".
- ↑ Mitchell, Alex J.; Shukla, Deepak; Ajumal, Hafsa A.; Stubbs, Brendon; Tahir, Tayyeb A. (2014). "The Mini-Mental State Examination as a diagnostic and screening test for delirium: systematic review and meta-analysis". General Hospital Psychiatry. 36 (6): 627–633. doi:10.1016/j.genhosppsych.2014.09.003. ISSN 0163-8343.
- ↑ Lippmann S, Perugula ML (2016). "Delirium or Dementia?". Innov Clin Neurosci. 13 (9–10): 56–57. PMC 5141598. PMID 27975002.
- ↑ Thom, Robyn P.; Levy-Carrick, Nomi C.; Bui, Melissa; Silbersweig, David (2019). "Delirium". American Journal of Psychiatry. 176 (10): 785–793. doi:10.1176/appi.ajp.2018.18070893. ISSN 0002-953X.