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Delirium tremens

Columbia Electronic Encyclopedia - Cite This Source

delirium tremens, hallucinatory episodes that may occur during withdrawal from chronic alcoholism, popularly known as the DTs. An episode of delirium tremens is usually preceded by disturbed sleep and irritability, and generally takes several days to develop. The patient may experience sweating and increases in heart rate and body temperature, as well as hallucinations, tremors, and convulsions. In severe cases, delirium tremens may lead to hypothermia, cardiovascular collapse, and death. Delirium tremens can be treated, and even prevented, by the injection of fairly large doses of glucose, thiamine (vitamin B1), and insulin, and the continued administration of fluids (sodium chloride and sodium lactate) and the B vitamins. The condition is related to the abrupt drop in blood alcohol level after drinking ceases. Tranquilizers, sedatives, and anticonvulsants are also used in treatment.

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Delirium

The Gale Encyclopedia of Mental Disorders - Cite This Source

Definition

Delirium is a medical condition characterized by a vascillating general disorientation, which is accompanied by cognitive impairment, mood shift, self-awareness, and inability to attend (the inability to focus and maintain attention). The change occurs over a short period of time— hours to days— and the disturbance in consciousness fluctuates throughout the day.

Description

The word delirium comes from the Latin delirare. In its Latin form, the word means to become crazy or to rave. A phrase often used to describe delirium is "clouding of consciousness," meaning the person has a diminished awareness of their surroundings. While the delirium is active, the person tends to fade into and out of lucidity, meaning that he or she will sometimes appear to know what's going on, and at other times, may show disorientation to time, place, person, or situation. It appears that the longer the delirium goes untreated, the more progressive the disorientation becomes. It usually begins with disorientation to time, during which a patient will declare it to be morning, even though it may be late night. Later, the person may state that he or she is in a different place rather than at home or in a hospital bed. Still later, the patient may not recognize loved ones, close friends, or relatives, or may insist that a visitor is someone else altogether. Finally, the patient may not recognize the reason for his/her hospitalizationand might accuse staff or others of some covert reason for his/her hospitalization (see example below). In fact, this waxing and waning of consciousness is often worse at the end of a day, a phenomenon known as "sundowning."

A delirious patient will have a difficult time with most mental operations. Due to the fact that the patient is unable to attend consistently to his environment, he/she can become disoriented. Nevertheless, disorientation and memory loss are not essential to the diagnosisof delirium; the inability to focus and maintain attention, however, is essential to rendering a correct diagnosis. Left unchecked, delirium tends to transition from inattention to increased levels of lethargy, leading to torpor, stupor, and coma. In its other form, delirious patients become agitated and almost hypervigilant, with their sleep-wake cycle dramatically altered, fluctuating between great guardedness and hypersomnia(excessive drowsiness) during the day and wakefulness during the night. Delirious patients can also experience hallucinationsof the visual, auditory, or tactile type. In such cases, the patient will see things others cannot see, hear things others cannot hear, and/or feel things that others cannot, such as feeling as though his or her skin is crawling. In short, the extremes of delirium range from the appearance of simple confusion and apathyto the anxious, agitated, and hyperactive type, with some patients experiencing both ends of the spectrum during a single episode. It is imperative that a quick evaluation occur if delirium is suspected, because it can lead to death.

Causes and symptoms

Causes

While the symptoms of delirium are numerous and varied, the causes of delirium fall into four basic categories: metabolic, toxic, structural, and infectious. Stated another way, the bases of delirium may be medical, chemical, surgical, or neurological. Many metabolic disorders, such as hypothyroidism, hyperthyroidism, hypokalemia, anoxia, etc. can cause delirium. For example, hypothyroidism (the thyroid gland emits reduced levels of thyroid hormones) brings about a change in emotional responsiveness, which can appear similar to depressive symptoms and cause a state of delirium. Other metabolic sources of delirium involve the dysfunction of the pituitary gland, pancreas, adrenal glands, and parathyroid glands. It should be noted that when a metabolic imbalance goes unattended, the brainmay suffer irreparable damage.

One of the most frequent causes of delirium in the elderly is overmedication. The use of medications such as tricyclic antidepressants and antiparkinsonian medications can bring about an anticholinergic toxicity and subsequent delirium. In addition to the anticholinergic drugs, other drugs that can be the source of a delirium are:

  • anticonvulsants, used to treat epilepsy
  • antihypertensives, used to treat high blood pressure
  • cardiac glycosides, such as Digoxin, used to treat heart failure
  • cimetidine, used to reduce the production of stomach aciddisulfiram, used in the treatment of alcoholism
  • insulin, used to treat diabetes
  • opiates, used to treat pain
  • phencyclidine (PCP), used originally as an anesthetic, but later removed from the market, now only produced and used illicitly
  • salicylates, basically found in aspirin
  • steroids, sometimes used to prevent muscle wasting in bedridden or other immobile patients

Additionally, systemic poisoning by chemicals or compounds such as carbon monoxide, lead, mercury, or other industrial chemicals can be the source of delirium.

Just as the ingestion of certain drugs may cause delirium in some patients, the withdrawal of drugs can also cause it. Alcohol is the most widely used and most well known of these drugs whose withdrawal symptoms may include delirium. Delirium onset from the abstinence of alcohol in a chronic user can begin within three days of cessation of drinking. The term delirium tremens is used to describe this form of delirium. The resulting symptoms of this delirium are similar in nature to other delirious states, but may be preceded by clear-headed auditory hallucinations. In other words, the delirium has not begun, but the patient may experience auditory hallucinations. Delirium tremens follow and can have ominous consequences with as many as 15% dying.

Some of the structural causes of delirium include vascular blockage, subdural hematoma, and brain tumors. Any of these can damage the brain, through oxygen deprivation or direct insult, and cause delirium. Some patients become delirious following surgery. This can be due to any of several factors, such as: effects of anesthesia, infections, or a metabolic imbalance.

Infectious diseases can also cause delirium. Commonly diagnosed diseases such as urinary tract infections, pneumonia, or fever from a viral infection can induce delirium. Additionally, diseases of the liver, kidney, lungs, and cardiovascular system can cause delirium. Finally, an infection, specific to the brain, can cause delirium. Even a deficiency of thiamin (vitamin B1) can be a trigger for delirium.

Symptoms

Symptoms of delirium include a confused state of mind accompanied by poor attention, impaired recent memory, irritability, inappropriate behavior (such as the use of vulgar language, despite lack of a history of such behavior), and anxiety and fearfulness. In some cases, the person can appear to be psychotic, fostering illusions, delusions, hallucinations, and/or paranoia. In other cases, the patient may simply appear to be withdrawn and apathetic. In still other cases, the patient may become agitated and restless, unable to remain in bed, and feel a strong need to pace the floor.

A few examples of people affected by delirium follow:

  • One gentleman, who had already been in the hospital for three days, when asked if he knew where he was, stated the correct city and hospital. He immediately followed this by saying, "but I started out in Dallas, Texas this morning." The hospital location was some 1,800 miles from Dallas, Texas, and as previously indicated, he had been in the same hospital for three days.
  • In another case, an elderly gentleman was placed in a private room that had a wonderful large mural on one wall. The mural was that of a forest scene—no animals or people, only trees and sunlight. His chief complaint at various points during the day was that evil people were watching him from behind the trees in the forest scene.
  • An elderly woman had to be subdued while attempting to flee from the hospital, because she was convinced that she had been brought there so surgeons could harvest her organs. Despite the lack of surgical scars or incisions, she insisted that she had been taken to the basement of the hospital the previous night and a surgeon had removed one of her kidneys.

Demographics

Delirium occurs most frequently in the elderly and the young, but can occur in anyone at any age. Of persons over 65 who are brought to the hospital for a general medical condition, roughly 10% show signs of delirium at admission. It is suspected that another 10%-15% may develop delirium while in the hospital. There appears to be no gender difference—delirium seems to affect males and females equally.

Diagnosis

Whether or not delirium is diagnosed in a patient depends on the type manifest. If the case is an elderly, postoperative patient who appears quiet and apathetic, the condition may go undiagnosed. However, if the patient presents with the agitated, uncooperative type of delirium, it will certainly be noticed. In any case, where there is sudden onset of a confused state accompanied by a behavioral change, delirium should be considered. This is not intended to imply that such a diagnosis will be made easily.

Frequent mental status examinations, at various times throughout the day, may be required to render a diagnosis of delirium. This is generally done using the Mini-Mental State Examination(MMSE). This abbreviated form of mental status examination begins by first assessing the patient's ability to attend. If the patient is inattentive or in a stuporous state, further examination of mental status cannot be done. However, assuming the patient is able to respond to questions asked, the examination can proceed. The Mini-Mental State Exam assesses the areas of orientation, registration, attention and concentration, recall, language, and spatial perception. Another recently evaluated and recommended tool for use in diagnosing delirium is the Delirium Rating Scale-Revised-98. This clinician-rated, 16-item scale allows for the assessment of 13 severity items and three diagnostic items. This test has been reported as more sensitive than the MMSE at detecting delirium.

At times, the untrained observer may mistake psychotic features of delirium for another primary mental illness such as schizophreniaor a manic episodesuch as that associated with bipolar disorder. However, it should be noted that there are major differences between these diagnoses and delirium. In people who have schizophrenia, their odd behavior, stereotyped motor activity, or abnormal speech persists in the absence of disorientation like that seen with delirium. The schizophrenic appears alert and although his/her delusions and/or hallucinations persist, he/she could be formally tested. In contrast, the delirious patient appears hapless and disoriented, between episodes of lucidity. The delirious patient may not be testable. A manic episode could be misconstrued for agitated delirium, but consistency of elevated mood would contrast sharply to the less consistent mood of the delirious patient. Once again, delirium should always be considered when there is a rapid onset and especially when there is waxing and waning of the ability to attend and the confusion state.

Since delirium can be superimposed into a pre-existing dementia, the most often posed question, when diagnosing delirium, is whether the person might have dementia instead. Both cause disturbances of memory, but a person with dementia does not reflect the disturbance of consciousness depicted by someone with delirium. Expert history taking is a must in differentiating dementia from delirium. Dementia is insidious in nature and thus progresses slowly, while delirium begins with a sudden onset and acute symptoms. A person with dementia can appear clear-headed, but can harbor delusions not elicited during an interview. One does not see the typical fluctuation of consciousness in dementia that manifests itself in delirium. It has been stated that, as a general rule, delirium comes and goes, but dementia comes and stays. Delirium rarely lasts more than a month. Usually, by the end of that period, a patient with dementia has full-blown dementia or has died. As a final caution, the clinician must be prepared to rule out factitious disorderand malingeringas possible causes for the delirium.

When a state of delirium is confirmed, the clinician is faced with the task of making the diagnosis in appropriate context to its cause. The delirium may be caused by a general medical condition. In such a case, the clinician must identify the source of the delirium within the diagnosis. For example, if the delirium is caused by liver dysfunction, wherein the liver is unable to clean the system of toxins, thereby allowing them to enter the system and so the brain, the diagnosis would be Delirium Due to Hepatic Encephalopathy. The delirium might also be caused by a substance such as alcohol. To render a diagnosis of Alcohol Intoxication Delirium, the cognitive symptoms should be more exaggerated than those found in intoxication syndrome. The delirium could also be caused by withdrawal from a substance. Continuing the alcohol theme, the diagnosis would be Alcohol Withdrawal Delirium (delirium tremens could be a feature of this diagnosis).

There may be instances in which delirium has multiple causes, such as when a patient has a head trauma and liver failure, or viral encephalitis and alcohol withdrawal. When delirium comes from multiple sources, a diagnosis of delirium precedes each medical condition that contributes. As an example, the multiple causes would be reflected as Delirium Due to Head Trauma and Delirium Due to Hepatic Encephalopathy. Finally, when delirium is the focus of clinical attention, but insufficient evidence exists to identify a specific causal factor, a diagnosis of Delirium Not Otherwise Specified is rendered. An example of this can occur in people who are exposed to sensory deprivation, such as might occur in Intensive Care Units or Cardiac Care Units where the patient is allowed no stimulation save that of the occasional member of the hospital staff.

In summary, delirium develops rapidly, has a fluctuating course involving waxing and waning lucidity, severely affects attention, must receive immediate medical attention, and is reversible in most cases.

Treatment

Treating delirium means treating the underlying illness that is its basis. This could include correcting any chemical disparities within the body, such as electrolyte imbalances, the treatment of an infection, reduction of a fever, or removal of a medication or toxin. A review of anticholinergic effects of medications administered to the patient should take place. It is suggested that sedatives and hypnotic-type medications not be used; however, despite the fact that they can sometimes contribute to delirium, in cases of agitated delirium, the use of these may be necessary. Medications that are often used to treat agitated delirium include haloperidol, thioridazineand risperidone. These can reduce the psychotic features and curb some of the volatility of the patient, but they are only treating symptoms of the delirium and not the source. Benzodiazepines (medications that slow the central nervous system to relax the patient) can also assist in controlling agitated patients, but since they can contribute to delirium, they should be used in the lowest therapeutic doses possible. The reduction and discontinuance of all psychotropic drugs should be the goal of treatment and occur as soon as possible to permit recovery and viable assessment of the patient.

Prognosis

If a quick diagnosis and treatment of delirium occurs, the condition is frequently reversible. However, if the condition goes unchecked or is treated too late, there is a high incidence of mortality or permanent brain damage associated with it. The underlying illness may respond quickly to a treatment regimen, but improvement in mental functioning may lag behind, especially in the elderly. Moreover, one study disclosed that one group of elderly survivors of delirium, at three years following hospital discharge, had a 33% higher rate of death than other patients. As a final note, delirium is a medical emergency, requiring prompt attention to avoid the potential for permanent brain damage or even death.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Kaplan, Harold and Benjamin Sadock. Synopsis of Psychiatry.8th edition. New York: Lippincott, Williams and Wilkins, 1997.

The Merck Manual.17th edition. Whitehouse Station, N.J.: Merck Research Laboratories, 1999.

PERIODICALS

Chan, Daniel. "Delirium: Making the diagnosis, improving the prognosis." Geriatrics54 (1999): 28-42.

Curyto, Kim J., Jerry Johnson, Thomas TenHave, Jana Mossey, Kathryn Knott, and Ira R. Katz. "Survival of Hospitalized Elderly Patients With Delirium: A Prospective Study." American Journal of Geriatric Psychiatry9 (2001): 141-147.

Katz, Ira R., Kim J. Curyto, Thomas TenHave, Jana Mossey, Laura Sands, and Michael Kallan. "Validating the Diagnosis of Delirium and Evaluating its Association With Deterioration Over a One-Year Period." American Journal of Geriatric Psychiatry9 (2001): 148-159.

Trzepacz, Paula T. "The Delirium Rating Scale: Its Use in Consultation-Liaison Research." Psychosomatics40 (1999): 193-204.

Trzepacz, Paula T., Dinesh Mittal, Rafael Torres, Kim Kanary, John Norton, and Nita Jimerson. "Validation of The Delirium Rating Scale-Revised-98: Comparison with the delirium rating scale and the cognitive test for delirium." Journal of Neuropsychiatry and Clinical Neuroscience13 (2001): 229-242.

Webster, Robert and Suzanne Holroyd. "Prevalence of Psychotic Symptoms in Delirium." Psychosomatics41 (2000): 519-522.

Jack H. Booth, Psy.D.

The Gale Encyclopedia of Mental Disorders
Copyright © 1999 by The Gale Group.
Published by The Gale Group. All rights reserved, including the right of reproduction in whole or in part in any form.

Delirium

Wikipedia, the free encyclopedia - Cite This Source

Delirium is an acute and relatively sudden (developing over hours to days) decline in attention-focus, perception, and cognition. In medical usage it is not synonymous with drowsiness, and may occur without it. It is commonly associated with a disturbance of consciousness (eg, reduced clarity of awareness of the environment). The change in cognition (memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance, must be one that is not better accounted for by a preexisting, established, or evolving dementia. Usually the rapidly fluctuating time course of delirium is used to help in the latter distinction.

Because it represents a change in cognitive function, the diagnosis cannot be made without knowledge of the affected person's baseline level of cognitive function.

Without careful assessment, delirium can easily be confused with a number of psychiatric disorders because many of the signs and symptoms are conditions present in dementia, depression, and psychosis. Delirium is probably the single most common acute disorder affecting adults in general hospitals. It affects 10-20% of all hospitalized adults, and 30-40% of elderly hospitalized patients.

Delirium itself is not a disease, but rather a clinical syndrome (a set of symptoms), which result from an underlying disease or new problem with mentation. Like its components (inability to focus attention and various impairments in awareness and temporal and spacial orientation), delirium is simply the common symptomatic manifestation of early brain or mental dysfunction (for any reason).

Distressing symptoms of delirium are sometimes treated with antipsychotics, preferably those with minimal anticholinergic activity, such as haloperidol or risperidone, or else with benzodiazepines, which decrease the anxiety felt by a person who may also be disoriented, and has difficulty completing tasks. However, since these drug treatments do not address the underlying cause of delirium, and may mask changes in delirium which themselves may be helpful in assessing the patient's underlying changes in health, their use is difficult. Because delirium is a mere symptom of another problem which may be very subtle, the wisdom of treatment of the delirious patient with drugs must overcome natural skepticism, and requires a high degree of skill.

Common usage of the term versus standard medical usage

In common usage, delirium is often used to refer to drowsiness and disorientation. In broader medical terminology, however, a number of other symptoms, including sudden inability of focus attention, and even (occasionally) sleeplessness and severe agitation and irritability, are also defined as "delirium."

There are several medical definitions of delirium (including those in the DSM-IV and ICD-10). However, all include some core features.

The core features are:

  • Disturbance of consciousness (that is, reduced clarity of awareness of the environment, with reduced ability to focus, sustain, or shift attention)
  • Change in cognition (e.g., problem-solving impairment or memory impairment) or a perceptual disturbance
  • Onset of hours to days, and tendency to fluctuate.

Common features also tend to include:

  • Intrusive abnormalities of awareness and affect, such as hallucinations or inappropriate emotional states.

Differential Diagnoses

Differential points from other processes and syndromes that cause cognitive dysfunction:

  • Delirium may be distinguished from psychosis, in which consciousness and cognition may not be impaired (however, there may be overlap, as some acute psychosis, especially with mania, is capable of producing delirium-like states).
  • Delirium is distinguished from dementia (chronic organic brain syndrome) which describes an "acquired" (non-congenital) and usually irreversible cognitive and psychosocial decline in function. Dementia usually results from an identifiable degenerative brain disease (for example Alzheimer disease or Huntington's disease). Once again dementia is not associated with a change in level of consciousness.
  • Delirium is distinguished from depression.
  • Delirium is distinguished by time-course from the confusion and lack of attention which result from long term learning disorders and varieties of congenital brain dysfunction. Delirium has also been referred to as 'acute confusional state' or 'acute brain syndrome'. The key word in both of these descriptions is "acute" (meaning: of recent onset), since delirium may share many of the clinical (i.e., symptomatic) features of dementia, developmental disability, or attention-deficit hyperactivity disorder, with the important exception of symptom duration.

It is a corollary of the above differential criteria that a diagnosis of delirium cannot be made without a previous assessment or knowledge of the affected person's baseline level of cognitive function.

Causes

Delirium may be caused by severe physical or mental illness, or any process which interferes with the normal metabolism or function of the brain. For example, fever, pain, poisons (including toxic drug reactions), brain injury, surgery, traumatic shock, severe lack of food or water or sleep, and even withdrawal symptoms of certain drug and alcohol dependent states, are all known to cause delirium.

In addition, there is an interaction between acute and chronic symptoms of brain dysfunction; delirious states are more easily produced in people already suffering with underlying chronic brain dysfunction.

A very common cause of delirium in elderly people is a urinary tract infection, which is easily treatable with antibiotics, reversing the delirium.

A mnemonic for the myriad causes of Delirium is:

  • Infections (Pneumonia, Urinary Tract Infections)
  • Withdrawal (Ethanol,opiate)
  • Acute Metabolic (acidosis, renal failure, imbalances, alkalosis)
  • Trauma (acute severe pain)
  • Central nervous system pathology (epilepsy, cerebral haemorrhage)
  • Hypoxia
  • Deficiencies (vitamin B12, thiamine)
  • Endocriopathies (thyroid, parathyroid, hypopituitarism, hyper/hypoglycemia, Cushing's)
  • Acute vascular (Stroke, MI, PE, heart failure)
  • Toxins/drugs (prescribed - Tramadol, recreational)
  • Heavy metals

Commonly co-occurring mental symptoms, with a note on severity

Since delirium may occur in very many grades of severity, all symptoms may occur with varying degrees of intensity. A mild disability to focus attention may result in only a disability in solving the most complex problems. As an extreme example, a mathematician with the flu may be unable to perform creative work, but otherwise may have no difficulty with basic activities of daily living. However, as delirium becomes more severe, it disrupts other mental functions, and may be 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. This may be apparent in disorganised 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) describes the loss of awareness of the surroundings, environment and context in which the person exists. It may also appear with delirium, but it is not required, as noted below. Disorientation may occur in time (not knowing what time of day, day of 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. Thus, a patient who is fully aware of where they are and who they are, but cannot think because they cannot concentrate, may be 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 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 to cognition may include temporary reduction in the ability to form short-term or long-term memory. Difficult short-term memory tasks like ability 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 formation of new long-term memory (which by definition survive withdrawal of attention), is common in delirium, because 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 need of concentration, previously formed long-term memories (i.e., 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 (i.e., they are temporary delusions). Interestingly, in some cases sufferers 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 inability to distinguish reality from dreams.

Abnormalities of affect which may attend the state of delirium 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.

Duration

The duration of delirium is typically affected by the underlying cause. If caused by a fever, the delirious state often subsides as the severity of the fever subsides. However, it has long been suspected that in some cases delirium persists for months and that it may even be associated with permanent decrements in cognitive function. Barrough said in 1583 that if delirium resolves, it may be followed by a "loss of memory and reasoning power." Recent studies bear this out, with cognitively normal patients who suffer an episode of delirium carrying an increased risk of dementia in the years that follow. In many such cases, however, delirium undoubtedly does not have a causal nature, but merely functions as a temporary unmasking with stress, of a previously unsuspected (but well-compensated) state of minimal brain dysfunction (early dementia).

Causation

Delirium, like mental confusion, is a very general and nonspecific symptom of organ dysfunction, where the organ in question is the brain. In addition to many organic causes relating to a structural defect or a metabolic problem in the brain (analogous to hardware problems in a computer), there are also some psychiatric causes, which may also include a component of mental or emotional stress, mental disease, or other "programming" problems (analogous to software problems in a computer).

Too many to list by specific pathology, general categories of cause of delirium include:

Gross structural brain disorders

  • Head trauma (i.e., concussion, traumatic bleeding, penetrating injury, etc.)
  • Gross structural damage from brain disease (stroke, spontaneous bleeding, tumor, etc.)

Neurological disorders

Circulatory

Lack of essential metabolic fuels, nutrients, etc.

Toxication

  • Intoxication various drugs, alcohol, anesthetics
  • Sudden withdrawal of chronic drug use ("de-tox") in a person with certain types of drug addiction (e.g. alcohol, see delirium tremens, and many other sedating drugs)
  • Poisons (including carbon monoxide and metabolic blockade)
  • Medications including psychotropic medications

Mental illness per se is not a cause, as a matter of definition

Some mental illnesses, such as mania, or some types of acute psychosis, may cause a rapidly fluctuating impairment of cognitive function and ability to focus. However, they are not technically causes of delirium, since any fluctuating cognitive symptoms that occur as a result of these mental disorders are considered by definition to be due to the mental disorder itself, and to be a part of it. Thus, physical disorders can be said to produce delirium as a mental side-effect or symptom; however primary mental disorders which produce the symptom cannot be put into this category, once identified. However, such symptoms may be impossible to distinguish clinically from delirium resulting from physical disorders, if a diagnosis of an underlying mental disorder has yet to be made.

Accounts of delirium

Sims (1995, p.31) points out a "superb detailed and lengthy description" of delirium in The Stroller's Tale from Charles Dickens' The Pickwick Papers.

Treatment of Delirium

Delirium is not a disease, but a syndrome (i.e. collection of symptoms) indicating dysfunction of the brain, in the same way shortness of breath describes dysfunction of the respiratory system, but does not identify the disorder. Treatment of delirium is achieved by treating the underlying dysfunction cause, or in many cases, the causes (plural), as delirium is often multi-factorial.

Antipsychotics are the treatment of choice for distressing symptoms although ones with minimal anticholinergic activity, such as haloperidol or risperidone are preferable. Benzodiazepines are usually used in alcohol withdrawal.

References

Further reading

See also

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