PSYCHOLOGY AND SOCIOLOGY

ASSIGNMENT-1
TOPIC:DELIRIUM SUBMITTED TO: PROF. PREETHI THABITHA SUBMITTED BY: ADELINE STEFFI.U 08BEC014 G1 SLOT-TT 205

COGNITIVE DISORDER
These psychological disorders are those that involve cognitive abilities such as memory, problem solving and perception. Some anxiety disorder, mood disorders and psychotic disorders are classified as cognitive disorders. Types of cognitive disorders include:

Alzheimer's disease Delirium / ORGANIC MENTAL DISORDER Dementia Amnesia

DELIRIUM
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.
1. state of violent mental agitation

[syn: craze, frenzy, fury, hysteria] 2. a usually brief state of excitement and mental confusion often accompanied by hallucinations Delirium (acute confusional state) is a common and severe neuropsychiatric syndrome with core features of acute onset and fluctuating course, attentional deficits and generalized severe disorganization of behavior. It typically involves other cognitive deficits, changes in arousal (hyperactive, hypoactive, or mixed), perceptual

deficits, altered sleep-wake cycle, and psychotic features such as hallucinations and delusions. It is often caused by a disease process 'outside' the brain, such as common forms of infection (UTI, pneumonia) or by drug effects, particularly anticholinergic or other CNS depressants (benzodiazapenes and opioids). It can also be caused by virtually any primary disease of the central nervous system. Though hallucinations and delusions are sometimes present, these are not required for the diagnosis, and the symptoms of delirium are clinically distinct from those induced by psychosis or hallucinogens (with the exception of deliriants.) Although commonly referred to as a primary disorder of attention, other core cognitive processes are disrupted, particularly working memory and virtually all aspects of executive functions (planning and organization of behavior). Although it is commonly regarded as reversible, induction of delirium in patients with dementia due to Alzheimer's disease appears to accelerate cognitive decline, suggesting that efforts to prevent and minimize the induction of confusional states in the elderly should be given high priority. Unfortunately, many instances of acute confusional state (delirium) are iatrogenic (precipitated by medicines or hospitalborne pathogens/bacteria or surgeries and anesthesia).

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 hospitalization and 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 diagnosis of 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 hallucinations of 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 apathy to 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.

TYPES OF DELIRIUM 1. Hyperactive or hyperalert the patient is hyperactive, combative and uncooperative. May appear to be responding to internal stimuli Frequently these patients come to our attention because they are difficult to care for.

2.Hypoactive or hypoalert

appears to be napping on and off throughout the day Unable to sustain attention when awakened, quickly falling back asleep Misses meals, medications, appointments Does not ask for care or attention This type is easy to miss because caring for these patients is not problematic to staff
3. Mixed a combination of both types just described The most common types are hypoactive and mixed accounting for approximately 80% of delirium cases

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 brain may 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 acid disulfiram , 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. Delirium is most often caused by physical or mental illness and is

usually temporary and reversible. Many disorders cause delirium, including conditions that deprive the brain of oxygen or other substances. Causes include: Drug abuse Infections such as urinary tract infections or pneumonia (in people who already have brain damage from stroke or dementia) Poisons Fluid/electrolyte or acid/base disturbances Patients with more severe brain injuries are more likely to get delirium from another illness.

DRUGS CAUSING DELIRIUM

Prescription drugs Central acting agents Sedative hypnotics (e.g., benzodiazepines) Anticonvulsants (e.g., barbiturates) Antiparkinsonian agents (e.g., benztropine, trihexyphenidyl) Analgesics Narcotics (NB. meperidine*) Non-steroidal anti-inflammatory drugs* Antihistamines (first generation, e.g., hydroxyzine) Gastrointestinal agents Antispasmodics H2-blockers* Antinauseants Scopolamine Dimenhydrinate Antibiotics Fluoroquinolones* Psychotropic medications Tricyclic antidepressants Lithium*

Cardiac medications Antiarrhythmics Digitalis* Antihypertensives (b-blockers, methyldopa) Miscellaneous Skeletal muscle relaxants Steroids

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 sceneno 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.

Delirium involves a quick change between mental states (for example, from lethargy to agitation and back to lethargy). Symptoms include: Changes in alertness (usually more alert in the morning, less alert at night) Changes in feeling (sensation) and perception Changes in level of consciousness or awareness Changes in movement (for example, may be inactive or slow moving) Changes in sleep patterns, drowsiness Confusion (disorientation) about time or place Decrease in short-term memory and recall *Unable to remember events since delirium began (anterograde amnesia) *Unable to remember past events (retrograde amnesia) Disrupted or wandering attention *Inability to think or behave with purpose *Problems concentrating Disorganized thinking *Speech that doesn't make sense (incoherent) *Inability to stop speech patterns or behaviors Emotional or personality changes *Anger *Anxiety *Apathy *Depression *Euphoria *Irritability Movements triggered by changes in the nervous system (psychomotor restlessness)

RISC FACTORS AND ETIOLOGY

Risk factors for delirium can be categorized as predisposing factors and precipitating factors. Predisposing factors of delirium include older age, male sex, visual impairment, presence of dementia, severity of dementia, depression, functional dependence, immobility, hip fracture, dehydration, alcoholism, severity of physical illness, stroke and metabolic abnormalities; while the precipitating factors include narcotics, severe acute illness, urinary tract infection, hyponatremia, hypoxemia, shock, anemia, pain, physical restraint, bladder catheter use, surgery, intensive care unit admission and a high number of hospital procedures (Rolfson, 2002). The etiology of delirium is usually multifactorial, and it has been reported that between two and six factors may be present in any single case (Rudberg et al., 1997). In a typical case, predisposing and precipitating factors interact with multiple aggravating or perpetuating factors which influence the course. It is therefore vital to be aware of risk factors and, having identified an explanation for delirium, remain vigilant as to the possibility of additional factors. The causes of delirium have been divided into patient factors, pharmacological factors, and environmental factors. Patient factors could be individual (like severe comorbidity, previous episode of delirium, and personality before illness), perioperative (like course of postoperative period, and type and duration of operation) and specific conditions (like depression and alcoholism). Pharmacological factors include treatment with many drugs, dependence on drugs or alcohol, use of psychoactive drugs or alcohol and specific drugs that may cause problems (like benzodiazepines, anticholinergic agents and narcotics); while environmental factors include extremes in sensory experience (for e.g., hypothermia), deficits in vision or hearing, immobility or decreased activity, social isolation and novel environment.

DERMOGRAPHICS
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 differencedelirium 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 clinicianrated, 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 schizophrenia or a manic episode such 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 fullblown dementia or has died. As a final caution, the clinician must be prepared to rule out factitious disorder and malingering as 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.

EXAMS AND TESTS

The following tests may have abnormal results: An exam of the nervous system (neurologic examination) Psychologic studies Tests of feeling (sensation), thinking (cognitive function), and motor function The following tests may also be done: Ammonia levels B12 level Blood chemistry (chem-20) Blood gas analysis Chest x-ray Cerebrospinal fluid (CSF) analysis CPK Drug, alcohol levels (toxicology screen) Electroencephalogram (EEG) Glucose test Head CT scan Head MRI scan Liver function tests Mental status test Serum calcium Serum electrolytes Serum magnesium Thyroid function tests Thyroid stimulating hormone level Urinalysis

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 , thioridazine and 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.

The goal of treatment is to control or reverse the cause of the symptoms. Treatment depends on the condition causing delirium. Diagnosis and care should take place in a pleasant, comfortable, nonthreatening, physically safe environment. The person may need to stay in the hospital for a short time. Stopping or changing medications that worsen confusion, or that are not necessary, may improve mental function. Medications that may worsen confusion include: Alcohol and illegal drugs Analgesics Anticholinergics Central nervous system depressants Cimetidine Lidocaine Disorders that contribute to confusion should be treated. These may include: Heart failure Decreased oxygen (hypoxia) High carbon dioxide levels (hypercapnia) Thyroid disorders Anemia Nutritional disorders Infections Kidney failure Liver failure Psychiatric conditions (such as depression) Treating medical and mental disorders often greatly improves mental function.

Medications may be needed to control aggressive or agitated behaviors. These are usually started at very low doses and adjusted as needed. Medications include: Dopamine blockers (haloperidol, olanzapine, risperidone, clozapine) Mood stabilizers (fluoxetine, imipramine, citalopram) Sedating medications (clonazepam or diazepam) Serotonin-affecting drugs (trazodone, buspirone) Thiamine Some people with delirium may benefit from hearing aids, glasses, or cataract surgery. Other treatments that may be helpful: Behavior modification to control unacceptable or dangerous behaviors Reality orientation to reduce disorientation 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.

PROGNOSIS

REFERENCE
1. 2. 3. 4. 5.

www.minddisorders.com http://www.uptodate.com http://emedicine.medscape.com http://health.nytimes.com http://www.psyplexus.com 6. http://psychology.about.com