Delirium in critically ill patients

DELIRIUM

Delirium is a state of confusion that can occur due to illness, surgery, or certain medications. There are many reasons for it and it can be difficult to immediately make an accurate diagnosis.

It usually begins suddenly and can frighten both the person experiencing it and those around him.

Delirium and dementia (dementia) may look similar. To quickly find out the reason for the patient’s inappropriate behavior, the doctor needs the help of loved ones - they will tell you how and when the strange condition began and how long it lasts.

About 0.5% of people aged 18 to 55 face this problem; 1.1% are from 56 to 85 years old and 13% are over 85 years old. It most often occurs in patients with HIV, malignancies (life-threatening tumors), or pre-existing cognitive impairment (problems with thinking).

The hypoactive type of delirium, which appears as confusion and apathy, can be easily overlooked or confused with depression.

Hyperactive is characterized by disorientation, agitation and delirium. It is similar to symptoms of schizophrenia.

Types of Delirium

Delirium can occur in various forms. Hyperactive delirium is most recognizable because patients with this form often fall or interfere with treatment. Hyperactive delirium is characterized by psychomotor agitation, agitation, verbal aggression, disorientation, visual illusions and belligerence.

However, two thirds of hospitalized patients with delirium are hypoactive and distracted. The hypoactive form of delirium is characterized by drowsiness and decreased concentration. Despite the fact that this type of delirium often goes unrecognized, its prognosis is extremely unfavorable.

The patient's cognitive status may fluctuate between these two subtypes of delirium. Therefore, it is important to remain vigilant for the various symptoms of delirium and to require 24-hour reports regarding the patient's behavior from nursing staff or family members.

Clinical approach

Elderly patients should be assessed for risk of having or developing delirium; Urgent measures to mitigate or eliminate precipitating factors should be taken, first of all, in relation to those patients who show signs or a high probability of developing delirium. Non-pharmacological methods - such as modification of the patient’s environment and the actions of persons. caregivers, including distraction, redirection, and reorientation techniques—are recommended as “first steps” in the prevention and treatment of delirium. Future treatment will benefit from multidisciplinary, multicomponent intervention.12,13

SYMPTOMS OF DELIRIUM

Symptoms of delirium are quite broad and include:

Hallucinations;
The person does not understand what is happening to him;
He doesn't know where he is;
Does not understand other people's speech and cannot speak clearly;
Sees vivid, often frightening dreams, the stories of which continue after waking up;
Feels agitated, restless and
Fear that others are trying to harm him;
Suffering from confusion in the head, which is worse in the evenings;
Feels drowsy and becomes sluggish;
Sleeps during the day and stays awake at night,
Experiences mood swings from fear and anxiety to depression or irritability,
Faces memory deficits, mainly short-term;
His ability to concentrate decreases;
Feelings change;
Urinary incontinence occurs.

ALCOHOLIC DELIRIUM

Alcoholic delirium, also known as delirium tremens, also known as alcohol withdrawal syndrome, also known as abstinence, also known as Delirium Tremens, also known as “squirrel”, is the most common type of psychosis that develops after alcohol withdrawal. Simply put, “squirrel” comes when you abruptly leave a binge, especially if they are regular.

Often, in addition to confusion, such patients also develop tremors - their hands shake and more. Most of those who abruptly give up alcohol do not experience withdrawal symptoms or have minor symptoms that do not require the participation of a doctor. About 25% require medical attention, and if left untreated, only 10% will develop more serious symptoms, such as seizures.

In the absence of medical care, from 5% to 15% of patients with such symptoms die.

Withdrawal has several stages.

First, acute intoxication (poisoning) occurs, then withdrawal syndrome, followed by a withdrawal attack, and it all ends with alcoholic delirium - delirium tremens.

Withdrawal syndrome can appear as early as 6 hours after the last drink and last 12–24 hours. Withdrawal symptoms include agitation, anxiety, tremors, nausea, mood swings, sweating, insomnia, and hallucinations (visual, auditory, or tactile). Moreover, with the latter, the patient realizes that these are hallucinations.

Withdrawal seizures occur with a frequency of 2% to 5%; together with the “squirrel”, they occur approximately 48 hours after the last dose of alcohol consumed. They manifest themselves in the form of tonic-clonic seizures, which begin with a spasm. In this case, the arms do not move, the legs are usually extended, and the eyes look up. The tongue is often bitten and involuntary urination occurs. Then the body twitches, and at the end of the attack the muscles relax.

Peak “squirrel” occurs 48–72 hours after drinking the last alcoholic drink. But 7–10 days after the “tie” the animal also comes. The following may already begin: delirium, sweating, fever, changes in heart rate, deep sleep, delirium, disorientation, fear or excitement, sensitivity to light, sound and touch.

In this condition, of course, hospitalization is necessary.

Infectious delirium

Read:

I. Delirium
II. Delirium
Alcoholic psychoses (delirium, hallucinosis, paranoid, Korsakov psychosis). Clinic and treatment.
ALCOHOLIC DELIRIUM (delirium tremens)
Alcoholic delirium, etiology, clinical picture, differential diagnosis.
Epstein-Barr disease. Infectious mononucleosis in children. Etiology, epidemiology, pathogenesis, clinical picture, course, treatment
Herpetic infection. Classification. Infectious mononucleosis. Clinic, diagnosis, treatment.
CHAPTER 138. INFECTIONS CAUSED BY EPSTEIN-BARR VIRUS, INCLUDING INFECTIOUS MONONUCLEOSIS
CHAPTER 188. INFECTIOUS ENDOCARDITIS
CHAPTER 23. CONFUSION, DELIRIUM, AMNESIA AND DEMENTIA

The phenomena of infectious delirium most often develop when the symptoms of the disease are quite pronounced, sometimes towards the end of it.

Although on the external side its manifestations are very diverse due to the fact that one particular side is brought to the fore, for example, excitement or delirium, one can nevertheless perceive a significant similarity in most cases, and one can speak of internal unity. The greatest diversity is observed in the degree of intensity of the darkening of consciousness. His deep darkness with complete loss of memory during the recovery period is observed only in a few cases. But even if you don’t touch them, you still have to reckon with a very large variety. In general, the blackout is more profound towards the end of the illness, but significant fluctuations are common within a short time. Sometimes persistent questions can seem to awaken the patient and force him to answer more or less consciously, if we are talking about relatively simple things, and then the consciousness becomes confused again. Thus, patients are usually able to name their name, year and occupation. The consciousness of the environment suffers to a much greater extent: patients are rarely able to correctly answer that they are in a hospital, much more often it seems to them that they are in the next world, among evil spirits, on a ship, lowered into some kind of bag, sitting under arrest etc. Of course, it is impossible to expect a clear consciousness of the disease, but from what the patients themselves say in response to a question or on their own initiative, one can see that many of them have a vague feeling of their illness, for example, patients say: “in my head fog and whirling”, “I’m confused”, “my death is coming”, etc.

The perception of patients is characterized by a pronounced tendency towards illusoryness. Even simple objects are often perceived with large errors (for example, many patients mistake a plessimeter for a knife or some other scary instrument, a pencil and a percussion hammer for a revolver); often objects are recognized correctly, but appear very distorted, for example, eyes are slanted, legs are crooked; sometimes all objects seem either too small or too large. A similar phenomenon is observed in relation to auditory material; for example, the word cough is perceived as porridge, sleep - alcohol, etc. We can probably say that the reason for such illusoryness should be considered to a certain extent a weakening of the activity of the higher sense organs; in particular, with typhus, significant weakening of hearing is common even where delirium is negligible or even completely absent. One can think of some vagueness of visual perceptions, which at least in part can be explained by purely physical phenomena, for example, hyperemia of the eyeballs. But the main reason undoubtedly lies in the inability to concentrate attention, in the disorder of associative activity, and in general mental acts. This is especially true where the patient is asked to do more complex work, for example, to read a passage. Although he correctly perceives individual letters, he almost never reads the words to the end, distorting them so that everything he reads does not make any sense.

The most characteristic of infectious delirium are hallucinations and associated delusional ideas. Visual deceptions need to be put in the foreground. The sick see that everything is burning all around, the end of the world is underway, there is war, the cavalry is attacking, a wall is falling on the sick person, they see some red pillars, gallows, some kind of temple with a supreme being on the throne, inviting the sick person to come to him. Sometimes in patients without a history of alcoholism, pressure on the eyeballs causes hallucinations even in those moments when they did not exist at all. Auditory hallucinations play a lesser role; the voices of relatives, screams, and gunshots are heard. As noted by all observations, delusions in infectious diseases are characterized by the fact that hallucinations are not isolated and scattered, but are in the nature of scenes. Moreover, the patient himself in these scenes is usually a direct participant, and not a spectator, as is the case in other conditions; the patient thinks that he is present at the wedding of his relative, participates in the attack, takes measurements from imaginary customers, plays a special game in which his life is the stake.

What can be called delusion is, in essence, the transmission of hallucinatory states without any attempt to critically relate to what the patient is experiencing. In accordance with hallucinations, patients usually think that they are making some kind of journey, traveling on a steamship, by rail, flying in an airplane, or climbing over some kind of ditch. According to Bongeffer, this feature of delirium in infectious diseases is explained by changes in the labyrinth and semicircular canals. According to our observations, these trips very often, especially with typhus, take on the character of catastrophes: patients think that they are becoming a victim of a railroad accident, an earthquake, or falling into some kind of abyss, and sometimes they persistently ask to hold them so as not to let them go somewhere. then fail; One typhus patient felt as if she had been turned upside down; others think they fly and fall, ride in a “shaky car,” fly through the air in a car with wings and have wings themselves.

Quite often professional delusion appears, and not only in cases of alcoholism; for example, a Red Army soldier from the railway guard sees the baskets and gives the order to check them in as luggage; a shoemaker talks about the nails he needs to make shoes, doctors perform operations and make a diagnosis, a psychiatrist with typhus delirium determines progressive paralysis from the attending physician.

Based on our observations, we would consider it possible to talk about the large role in the formation of delusional ideas of painful and generally unpleasant sensations in various organs, as something more or less typical for infectious delirium (especially with typhus). It is unusually common to observe this kind of delusional experience: a clock is ticking in the patient’s head, the side is shot in battle (complication of pleurisy), the patient’s legs are amputated or cats bite them (neuritic pain), they are cut in half with a saw (the patient, wrapped in damp sheets, was tied towel to the bed); the patient is quartered, cut into pieces, dropped into a bag filled with insects that bite him; one patient saw his entire body cut into pieces and boiled in cauldrons. Although memories of the past and creative fantasy take part in the creation of delirium, especially in the first days, it is still mainly the illusory perception of reality and hallucinatory images that provide material for delusional concepts. In severe cases, especially towards the end of the illness, one can always identify the participation of one or another painful sensation. The second thing that we first noticed was the delusion of doubling one’s personality or the delusion of a double. Most often it happens like this: it seems to the patient that someone else is lying on the bed with him, this someone is somehow connected with him; this is his brother or even a close relative; sometimes this other appears as some kind of appendage on the patient’s body, he is the patient, experiences pain, various unpleasant sensations and makes the patient himself suffer. Sometimes it seems to the patient that certain parts of his body have somehow doubled, for example, he “has two heads,” he has two mouths; In addition to his own arms and legs, he had some others. One must think that in a painful state, the organs of the body seem to be something alien, extraneous, not belonging to the patient himself. Interesting instructions are given by the patients themselves during the recovery period. After regaining consciousness, it seems to them for some time that their arms and legs, and their body in general, do not belong to them.

Intense pain in different parts of the body, characteristic of infectious diseases in general, is also caused by the often observed neuritis. In view of this, it is easy to understand why delirium of this nature is so common in typhus.

Sometimes allegorizing pain and other sensations in a similar way leads to delusions of obsession. One patient was convinced that she was being bitten and scratched by cats, one of which had climbed into her stomach, was fiddling around there and meowing; at the same time, the patient herself meowed, claiming at the same time that it was not she herself who was doing this, but the cat that had penetrated her. Another patient, suffering from gingivitis, for several days expressed delirium that an evil spirit had entered her mouth: she did not see him, but felt him in the form of some small furry creature, she tried to constantly squeeze him with her teeth, but somehow he he dodged, and the patient bit only her tongue and the mucous membrane of her cheeks.

Delusional ideas in all cases are very unstable, which is not surprising if we take into account the nature of their formation. For the most part, their content is unpleasant and painful for the sick. But there are cases, mainly among the milder ones, when the experiences of patients have the character of especially productive creativity; patients feel that they are making some discoveries and playing a big role in world events; at the same time, the state of health, during a certain period of illness at least, can be unusually good, even ecstatic.

The behavior of patients is largely determined by the delusional thoughts and hallucinatory images they experience; they fearfully look around, listen to something, defend themselves from imaginary enemies, resist physical examination, when performing infusions and injections. Very often you can see that they are experiencing a certain scene: for example, a Red Army soldier in delirium continues to fight with an imaginary enemy, swings his hand like a saber, shouts “fire.” Patients tend to relate everything that happens in the ward to themselves; the speech of others is mistaken for questions addressed to them and they try to answer. As an interesting detail, it can be noted that very often patients try to take off their clothes and especially tear off the deck bandages remaining after salt infusions. In them, the patients undoubtedly, as they themselves said, were inclined to see the personification of that unpleasant appendage, which they so often mentioned in their delirium. Several times I heard: “Take this away from me,” and when these stickers were removed, for a while the patients calmed down, thinking that exactly what needed to be done had been done. Often phenomena are observed that, from the outside, are very reminiscent of catatonic ones, namely the stereotypical repetition of the same word or phrase, rhythmic waving of the arms, sometimes freezing in the same position; sometimes you can be convinced that this movement corresponded to hallucinatory images; for example, the patient seems to be flying through the air and flapping his wings. The course of the illness in these cases did not represent anything special, and after the illness, as well as before it, there was no data that made it possible to assume schizophrenia; Some feature of such cases is a deeper darkening of consciousness. From a practical point of view, it is important to remember the quite often observed desire to leave and run away under the influence of hallucinations and delusions; sometimes there is a desire to jump out of the window, a tendency to harm oneself; in an effort to retain patients, a picture of very great excitement sometimes develops. As for the flow, the described phenomena usually continue until the temperature drops, and can often be observed after it. In some cases, during the recovery period, delusional ideas persist and persist, when all other painful phenomena have already disappeared. Such “residual delirium” does not represent anything specific to post-infectious conditions. In general, it is noted where the final disappearance of painful phenomena that arose in the acute period of the disease is prevented by either not fully cleared consciousness or mental weakness. Accordingly, such delirium is usually encountered after delirious states, in particular after alcoholic disorders, in epileptics in post-ictal states, sometimes after attacks of manic-depressive psychosis. Delusions of this kind have also been observed in connection with infectious diseases. It is clear why residual delirium is often observed after typhus. The reason is primarily the vividness of hallucinatory experiences during this disease, which makes it relatively easy to confuse them with reality. Apparently, the condition necessary for the development of residual delirium—a state, at least temporary, of a certain mental weakness—is present here to a greater extent than after any other infection. Finally, with typhus there are also more “residual” symptoms in the somatic and nervous sphere than in other cases—long-lasting weakness, weakness, pain, discomfort throughout the body, as well as the feeling that the body has somehow changed and even seems strangers The abundance of various sensations remaining from the acute period, characterized by hallucinatory experiences, contributes to the fact that the content of some of them gets stuck for the period after clearing consciousness due to the fact that the weakened psyche cannot immediately cope with the abundance of new experiences and give them a critical assessment. It is precisely this origin of a certain part of at least residual delusional ideas, namely the confusion of dreams with reality, that corresponds to their content, for which the principle of Wünscherfüllung (fulfillment of desire) is very suitable. The second type of residual delusion in content is ideas of persecution and theft. Their appearance is psychologically understandable from the above considerations. A special type, in our opinion, most characteristic of typhus, is hypochondriacal delusions associated with painful and generally altered sensations. An example would be the following case:

A doctor, surgeon, 60 years old, in a state of typhus delirium, along with other phenomena, experienced a special sensation that his head was made of glass; this feeling was so real that the patient held his head all the time as if he was afraid of breaking it, and forbade him to touch it, shouting that it was glass. After the temperature dropped and the hallucinatory phenomena proper disappeared, along with the clearing of consciousness, he still had this sensation and the fear of breaking his head for about two weeks. Any sudden movement of others near him caused the patient extreme fear and corresponding defensive movements. Gradually this phenomenon disappeared, and there was a transition period when he realized that his fear was absurd, but still could not free himself from it.

In some especially severe cases, the blackout continues for a longer time; For the most part, such patients die without any complications, with symptoms of adynamia caused precisely by the severity of the infection. Death sometimes occurs earlier, even at a high temperature, but also with a deep darkening of consciousness, usually together with phenomena of great motor restlessness, sometimes taking on the character of random tossing and actuation; These are the cases that give the authors reason to talk about so-called acute delirium. Convulsive twitching of the limbs, tonic tension in them indicate irritation of the meninges; sometimes bulbar symptoms can be observed, most often dysarthria and phonation disorder. The mortality rate in cases occurring with pronounced delirium is more than twice the average mortality rate in general; in particular, a deep blackout should be considered a very unfavorable sign, especially if it remains even after the temperature drops.

Each infection has its own characteristics to a certain extent during delirium. Most often it develops after typhus, somewhat less often after typhoid, and in such cases the course is particularly severe. With these infections, less often with others, at the onset of the disease sometimes special states of excitement are observed, close to manic, but having nothing to do with circular psychosis, but representing a peculiar course of the same delirium. Sometimes mental arousal of this kind is the first symptom of the disease noticeable to others. In one case, a patient with typhus fell into a pronounced manic state at the very beginning of the illness and ran away from home, was detained on the street and placed in a psychiatric hospital, where only the true cause of this excitement was found out. Typhus and typhoid fever tend to give especially severe pictures of post-infectious weakness. Relapsing fever, giving violent pictures of delirium, usually does not leave any lasting changes in the mental sphere. During scarlet fever, smallpox and malaria, there may be special states of excitation, reminiscent of what is observed in epileptics. In malaria, as established by A. A. Perelman, in addition to such excitation and hallucinatory states, an amental symptom complex is often observed. With influenza, the picture of infectious delirium is not a common phenomenon, but post-infectious states of weakness are very pronounced. Kleist noted that they are especially prone to depressive moments. Delirium with articular rheumatism and erysipelas can present a stormy picture. Diphtheria is characterized by frequent lesions of the peripheral nerves and gross focal lesions of the brain, while infectious delirium itself is rarely observed.

It must be borne in mind that the picture of infectious delirium, as such, can be complicated by symptoms depending on the accompanying inflammatory phenomena of encephalitis or meningitis, brain abscess, which sometimes develops in connection with suppuration of the ear, as well as uremia.

Treatment. According to the assumption of poisoning, salt infusions and salt enemas, and drinking plenty of fluids are widely used with undoubted benefit. Great subjective relief and objective improvement in the sense of clearing consciousness are provided by cool wraps of the whole body for 1/4-1/2 hour, dousing the head and, in general, local application of cold to the head; in stronger patients, general baths with cool douses are useful. Drug treatment is rational only in the sense of supporting the activity of the heart; By the way, the use of adrenaline along with an infusion is useful. To calm excitement, bromides and sleeping pills are useless and rather harmful; hints of improvement can be seen from ergotine; for melancholy excitement, an injection of morphine is useful. Any measures of restraint should be reduced to the possible minimum, which, taking into account the psychology of such patients, must be remembered more than anywhere else. Wet wraps are only useful for short-term use while they act in a cooling manner. It is necessary to protest most resolutely against the often practiced in general hospitals of binding such patients, the use of special beds with bars and all similar measures of violence. Moreover, they are not caused by necessity, since agitation in patients of this kind is very short-lived and can easily be prevented or weakened by the above measures. All patients with delirium should be constantly monitored.

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CAUSES OF DELIRIUM

Among hospitalized patients, delirium occurs regularly, affecting approximately 15–20%. And most often - in the elderly, with memory problems, dementia, after operations, brain injuries and in people with poor hearing and vision.

The most common causes of delirium:

Withdrawal syndrome: withdrawal from alcohol or drugs. The same “squirrel”;
Heat;
Strokes: ischemic, hemorrhagic, ischemic attack;
liver or kidney problems;
Major surgery (major surgery);
Epilepsy;
Trauma: traumatic brain injury and intracranial hematoma (bleeding in the brain);
Tumor: primary or metastatic brain tumor;
Inflammation or infection: inflammation of the blood vessels of the central nervous system, meningitis, encephalitis, meningoencephalitis.
Migraine that affects consciousness.
Disturbances in the endocrine system: Cushing's syndrome; long-term effects on the body of adrenal hormones, adrenal or pituitary insufficiency, thyroid diseases;
Sensory deprivation (deprivation of senses);
Prolonged stay in the intensive care unit;
Blood problems: hyperviscosity syndrome, thrombocytopenia, polycythemia, leukemic blast crisis;
Medicines: anticholinergics, antihistamines, antiemetics, hypotensives, blood pressure lowerers, benzodiazepines, psychoactive substances with sedative, anti-anxiety, muscle relaxant and anticonvulsant effects, corticosteroids, hormonal drugs, for example, cortisol, hydrocortisone, dexamethasone, prednisolone, dopamine agonists used in Parkinson's disease or to suppress breast milk production : for example, cabergoline, bromocriptine, pramipexole, ropinirole, muscle relaxants, sedatives taken to relax muscles: for example, mydocalm, sirdalud, baklosan, calmirex, antispasmodics that relieve spasms: for example, spazgan, spasmalgon, maxigan, digoxin, sleeping pills, opioids, sedatives, antidepressants;
Infection: sepsis, general infection, urinary tract, pneumonia, fever;
Injuries: burns, hypothermia, heat stroke, electrical trauma;
Sleep deprivation;
Urinary retention;
Mental disorders;
Metabolic disorders, improper amount of fluids and electrolytes in the body: hypernatremia (too much sodium), hyponatremia (severe sodium deficiency), hypocalcemia (not enough calcium), hypercalcemia (too much calcium), dehydration, hyperthermia (overheating), hypoglycemia (not enough sugar in the body). blood), hyperosmolarity (excess glucose and sodium), hypoxia (lack of oxygen);
Problems with the cardiovascular system: cardiac arrhythmia and failure, shock, hypoperfusion (insufficient blood supply to the body), anemia;
Deficiency of vitamins B12 and thiamine.

Causes and pathogenesis

Delirium, just like other forms of productive impairment of consciousness (oneiroid and amentia), does not act as an independent nosological unit. Such a diagnosis is syndromic. It is part of the general cerebral syndrome, which indicates general suffering and dysfunction of the central nervous system. Both urgent neurological diseases and severe somatic pathology can be the causes of the formation of delirious insanity.

The most common complications of delirium are:

severe diseases of internal organs;
acute surgical pathology;
infectious diseases;
postoperative period;
traumatic brain injuries;
cerebral neoplasms;
vascular pathology of the brain (especially subarachnoid hemorrhages);
intoxication;
uncontrolled use of certain medications (for example, anticholinergics).

The pathogenesis of delirious disorders is based on diffuse dysmetabolic processes in the brain as a result of prolonged and excessively strong external and/or internal influences. The triggered mechanism of neurotransmitter and neurotransmitter imbalance, as well as impaired oxygen metabolism, can lead to gross neural instability, clinically manifested by both hypoproductive and hyperproductive changes in the level of consciousness.

Classification

Delirium is a heterogeneous group of diseases. In this regard, separate types of such disorders are distinguished.

Depending on the qualitative change in consciousness, acute delirium can be hypoproductive (manifested by depression of consciousness) and hyperproductive (with symptoms of psychomotor agitation, affective disorders, hallucinations).

The delirious state is observed mainly in elderly patients and can be considered as a manifestation of senile psychosis. However, they can also occur among people of other age groups. In this regard, delirious disorders of children, adolescents, and senile delirium are distinguished.

The reasons for the formation of delirium form the basis of the etiological classification. According to it, they distinguish:

toxic delirium, including drug, alcohol, narcotic, infectious-toxic subtypes. Classic examples of this pathology are anticholinergic delirium, which is a consequence of an overdose of anticholinergic drugs, and delirium tremens, which develops with prolonged abuse of alcohol-containing products;
organic delirium, which is the result of a neurological or mental illness (neuroinfections, traumatic brain injury, schizophrenia, stroke, brain tumor);
somatogenic delirium is formed during decompensation of somatic diseases (for example, infections, diabetes, renal failure);
traumatic delirium, developing as a result of traumatic damage to the musculoskeletal system;
postoperative delirium, which occurs after surgery;
hysterical delirium, observed as part of hysterical neurosis and having a functional reversible nature.

The forms of delirious psychosis can be closely related and sometimes difficult to distinguish between them. In this case, there is a mixed genesis of mental disorders. For example, infectious delirium (in particular delirium due to pneumonia) can be considered as a variant of the toxic and somatogenic variant. And clouding of consciousness as a result of traumatic injuries is a particular manifestation of the postoperative subtype.

Clinic

Diagnosis of delirious stupefaction is based on an analysis of the clinical manifestations of the pathology.

The criteria for confirming delirious disorders are:

acute onset of mental disorders;
variability of mental disorders over time, as well as in structure;
attention and memory disorders (up to amnesia);
thinking disorders;
perception disorders with the possible appearance of visual, auditory, tactile, olfactory and gustatory hallucinations;
change in level of consciousness.

Typically, delirium is characterized by all of the above. However, only individual symptoms in different variations may be present in the clinic. In some cases, the full-blown clinical picture is preceded by transient episodes of confusion. Such conditions are defined as predelirium.

Additional signs of delirium may help in diagnosis. These include psychomotor disorders, sleep-wake cycle disorders, and emotional regulation disorders.

The disorder of consciousness within delirium disorders is defined as a decrease in conscious awareness of the environment and an inability to focus, maintain, or shift attention. Additionally, there is disorientation in time and space and impaired speech functions. The development of changes in consciousness is acute. The time required for the formation of a fully developed clinic is usually calculated in hours, less often in several days. Symptoms of delirium tend to fluctuate, i.e. able to change in severity throughout the day. In addition, to confirm delirium, laboratory or clinical evidence of the presence of a neurological or somatic disease, intoxication or other conditions that can lead to existing mental impairment is required. On the other hand, the connection between the existing clinic and the presence of dementia must be excluded.

Depending on the characteristics of the predominant symptoms, the following are distinguished:

professional delirium. The clinic includes disturbances in orientation in the real surrounding space. The patient believes that he is at his workplace, performing an imitation of professional motor acts. As a rule, the disorder is accompanied by motor agitation;
Oneiroid. The patient has predominant symptoms of complex gallicinosis, manifested in the form of fantastic and mystical-religious images and scenes. At the same time, orientation in one’s own personality is lost;
excruciating delirium, which is characterized by psychomotor agitation in bed. Patients shake themselves off, throw off non-existent objects, and clean themselves up. Speech function is reduced to inarticulate, meaningless nonsense. In terms of prognosis, it is an unfavorable form of consciousness disorder.

Considering that there is no specific laboratory and instrumental diagnosis of delirium, diagnosis is often based solely on anamnestic data provided by the patient’s relatives or collected on the basis of medical documentation (outpatient card or medical history). Difficulties in confirming mental disorders are also determined by the fact that at the stages of predelirious states, the patient’s behavior may not suffer significantly. In addition, delirious disorders can be masked by intellectual decline, some forms of amnesia and remain unrecognized for a long time.

DIAGNOSIS OF DELIRIUM

The doctor begins with an examination and medical history. It is advisable to come to the appointment with a loved one who knows how your illness progressed.

What else can the doctor do:

measure the level of magnesium and potassium in the blood,
take an electroencephalogram (EEG) to check brain activity,
MRI to find out if there are seizures or head trauma,
Take blood and urine tests.

A loved one has delirium. What to do?

When a person suddenly becomes confused, they should seek medical help immediately. Often the patient is too confused to tell doctors about his condition, then information about the disease is communicated to the doctor by family members or loved ones. If the manifestations of the disease are acute, for example, with aggression towards others or oneself, call an ambulance immediately; you definitely won’t be able to cope on your own.

Delirium infectious (febrile)

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Caring for patients with nervous and mental illnesses. Main pathological conditions

What are the general characteristics of infectious delirium?

This is an acute condition with psychomotor agitation, usually occurring at the height of acute infectious diseases (typhoid fever, childhood infections, pneumonia).

What are the early signs of infectious delirium?

Infectious delirium does not always occur suddenly. It is possible to notice its early signs. The change in the patient’s behavior is noteworthy: he becomes anxious, fussy, rushes about in bed, constantly changing body position, sometimes tries to get up, sometimes turns to others with the same requests several times, groans, cries, makes many unnecessary movements, refuses food. During this period, patients often find increased sensitivity to noise and bright light. By evening all these phenomena intensify. By this time, many patients begin to doze off or lie silently with their eyes wide open, intently looking at the walls and ceiling, listening to something, “loaded” with their experiences, and are extremely reluctant to answer questions.

What is characteristic of the advanced stage of delirium?

In the advanced stage of delirium, agitation occurs, more pronounced at night: the patient jumps out of bed, sometimes jumps out the window or runs naked into the street, breaks away from the hands of the people holding him. There is an expression of fear and anxiety on the face, the eyes are wide open and shining. The patient shouts out individual words, phrases, seems to be talking to someone, and answers questions. When you contact him, you may not get an answer right away. Being not oriented in time and place, the patient correctly answers questions about his own condition, says that he sees various pictures, is surrounded by animals or supernatural monsters that attack him, strangle him, torment him.

How is emergency first aid provided to a patient?

Patients with a severe infectious disease must be closely monitored; timely identification of signs of incipient delirium allows preventive measures to be taken. All this is the task of the nurse. In the advanced stage of delirium, along with physical restraint of the patient, persistent psychotherapy that calms the patient is necessary.

What drug treatment is prescribed to the patient?

Therapeutic measures for advanced infectious delirium include nonspecific sedatives, detoxification and neuroleptic sedative therapy. For detoxification, glucose is administered intravenously, large amounts of isotonic sodium chloride solution are administered subcutaneously in combination with vitamins C and B1, and drinking plenty of fluids.

In case of delirium against the background of severe somatic suffering, detoxification substances, drugs aimed at maintaining cardiovascular activity, and sedatives are used. Psychomotor agitation is eliminated by intramuscular administration of aminazine or tizercin at a dose of 25-50 mg as prescribed by a doctor, taking into account contraindications.