DETECTION AND MANAGEMENT OF DELIRIUM

Introduction

Delirium is a fluctuating, sudden and usually rescindable disturbance of mental

functioning more prevalent in elder people. It is generally characterized by attention
deficit, disorientation, insomnia, delusional thinking and fluctuations in the levels of
consciousness. In delirium delusional thinking is related to the themes, beliefs,
convictions of imaginary life, which is taken for reality and tends to develop and
organize the totality of existence. This cognitive confusion called delirium is categorized
into three types; known as hyperactive, hypoactive and mixed delirium. Hyperactive
delirium is relatively easy to detect, which may include frequent mood swings, agitation,
feeling of restlessness, agitation and repudiation to respond to the care. While another
type of delirium is characterized by reduced speech, feeling of apathy, motor retardation
and even patient can eventually be sedated. Mixed delirium contains the properties of
both hyperactive and hypoactive type of delirium. Delirium is a medical prognosis which
results from intricate relationship between vulnerability of patients and the precipitating
clinical conditions. For instance a patient with pre-existing cognitive impairment has high
prevalence rate of developing delirium.

Delirium and dementia by and large are associated with one another. The
occurrence rate of delirium is high in the patients of dementia, but its detection by
physicians is comparatively low. The occurrence of delirium is as high as 80% of the
dementia patients while failure to detect its prevalence is as high as 75% of all the
cases. Detection of delirium is critical because of its association with common poor
outcomes and its potential for preclusion by the avoidance of precipitating factors.
General poor outcomes of delirium may include prolonged physical and psychological
impairment, institutionalization, extended hospitalization and death. Rising healthcare
cost and increased ratio of aging population in UK has grabbed the attention of
stakeholders to invest their time and energy in the better detection and management of
delirium and other costly health conditions.

Aim of the Study

  To study the detection techniques and management tools of delirium.

Objectives

 To focus on the importance of early detection of the disease

 To assess the validity of detection techniques used in detection or recognition of
delirium
 To shed light on the management of the disorder
 To identify the relationship between detection and management

Literature Review

Delirium is a multidimensional psychological and neurological condition prevalent

in hospitalized elderly population (Ausra Deksnyte, 2012) and incidences rate increases
for those who already have cognitive impairment or any other serious illness. This
muddle state has varying symptoms for diagnosis such as restricted speech,
disorganized thinking, attention deficit, decreased motor activity, mood swings,
disturbed sleep-wake cycle and psychosis (MD, 2000). Presentation of symptoms varies
and depends upon cause, treatment provided to the patient, other co-morbidities, and
individual’s predisposition (Berrios, 2018).

Delirium word was first time used by Celsus in medical writings during the first
century AD (Dimitrios Adamis, 2007) in order to describe psychological or mental
ailments during head trauma or fever. In addition, he coined the term phrenitis as a
substitute to delirium. The term phrenitis was formerly used by Hippocrates in 500 BC
(Dimitrios Adamis, 2007) to define mental malformations caused by head trauma or
fever. It is claimed that the existing nomenclature of delirium is vague and confusing in
nature because of the names used to define it in history (R. Ryan Field, 2013). Though
various names are associated with delirium to define this syndrome precisely, the
clinical meaning of all these names remained consistent through-ought the time.
Hippocrates used sixteen different terms in order to define the syndrome which we
know as delirium these days.
 The term delirium is derived from a Latin word Deliro which has a bunch of
meanings including deviation from a straight line, silly, deranged, to be crazy, to rave
and to dote (Krishna Sahithi.J, 2017). There another notion exists about the etymology
of the syndrome that the word delirium has its roots in Greek language and is derived
from a word Leros which means nonsense or silly talks (Henderson, 2005). Whatever
the terms had been used to define the disorder but their meaning remained consistent.
Hippocrates believed that clenching during fever is the warning sign that a person may
develop delirium. He further claimed that the coexistence of delirium with gnashing
leads to the certainty of death. So, delirium is not studied alone and even today it is
known as multiplicity of syndromes (Dimitrios Adamis, 2007).

Glossary of the Term used to define the Disorder:

 Acute confusion
 Brain Failure
 Acuter Brain Syndrome
 Organic Psychosis
 ICU Psychosis
 Delirium
 Toxicity of CNS
 Insufficiency of Cerebrals
 Encephalopathy
 Toxicity of Metabolism
 Encephalitis
 Sun downing

The key issue in the detection of delirium is its definition. It generally echoes the
global failure of the cerebral metabolism of great variety of medical etiologies, until now
it is challenging to assess the impact of medical condition in the brain.

Delirium’s Risk Factors

Risk factors of delirium are generally divided into two categories, precipitating and
predisposing factors.

Precipitating Factors

 Hospitalization
 Drug Abuse
 Prolong use of Sedatives
 Emotional Distress
 Infections

Predisposing Factors

 Demography age > 60

 Restricted oral intake; malnutrition and dehydration
 Immobility
 Sensory Impairments
 Co-existence with other medical conditions
 Pre-existing cognitive impairment

Pathophysiology of Delirium

Epidemiological research has great contribution in the recognition of delirium

however, in order to develop effective and efficient preventive strategies an objective
understanding of its mechanism is required. Pathophysiology of delirium is not
completely understood although its prevalence is viewed generally under two
mechanisms called inflammatory mechanism and neural mechanism.

Neural Mechanism

Research indicates that adults are at higher risk of developing delirium so;
application of the concept of homeostenosis to the development of delirium suggests
that changes in the activity of brain which are associated with the age predispose older
people to delirium physiological malfunctions which are tolerated in young individuals.
Alteration in the brain activity with normal process of aging includes about 28% decline
in the neural blood flow and neurons also loss in various areas of the brain.
Neurotransmitters including dopamine, GABA, Serotonin and acetylcholine are
considered to be responsible in the pathogenesis of the disease.

Dopamine
 Dopamine elevation is associated with the onset of delirium. Dopaminergic drugs
are associated with a number of calcium channels and metabolic pathways which leads
to an earth-shattering increase in the level of dopamine under damaged oxidative
condition.

Acetylcholine

Acetylcholine is a neurotransmitter which plays vital role in consciousness and

attention (Tammy T. Hshiej, 2008). It is generally hypothesized that the consumptions of
drugs which impair cholinergic functioning can cause delirium. Acetylcholine focuses on
conscious state of mind by performing the role of modulator of signal-to-noise relation in
the mechanism of cognitive and sensory input; anomalies in these brain functionalities
may cause primary symptoms of hyperactive as well as hypoactive delirium, which
includes perceptual disruption, inattention, disorganized thinking and disruptive
behaviors (Tune L.E, 1999).

Glutamate

Glutamate is considered as a major excitatory neurotransmitter which is snugly

regulated, nevertheless the glutamate accumulation caused by inflammation leads to
the irresistible neuronal excitation which eventually results in death. Higher Intensive
Care Unit admission plasma glutamate concentration is associated with cognitive
malfunctioning; indicating glutamate excitotoxicity may play a pathogenic role in
neurocognitive sequelae in seriously sick sepsis sufferers (Brian J. Andreson, 2017).

Inflammatory Mechanism of Delirium

The absolute pathogenesis of the syndrome is still unclear despite, proposing

numerous mechanisms including dysregulation of the sleep-wake cycle, imbalance of
neurotransmitters; decreased metabolic rate and inflammation (Mark J. Simone, 2011).
Systematic inflammation is viewed in various conditions which are known to precipitate
changes in cognition of elderly population including surgery, lesions, cancer and
infections. Delirium is an acute cognitive decline associated with acute inflammatory
state. Aging alone as a primary indicator can cause an upsurge in peripheral cytokines.
A Study conducted on elder patients who were acutely admitted to the hospital
suggested that people who developed delirium were considerably more likely to have
noticeable levels of peripheral cytokines IL-8 and IL-6 after adjusting for cognitive
impairment, infection and age. The levels of peripheral IL-8 and IL-6 cytokines were
even raised in patients who were admitted to the hospital for the surgical procedure of
their hip fractures. The IL-8 is considered liable for the early onset of the disorder
whereas IL-6 is associated with the hyperactive type of delirium (de Rooij SE, 2007).