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Delirium? Now what?

Posted Apr 02 2013 10:16am

By Derek S. Mongold, MD

My father is in the hospital and they say that he has delirium. What exactly is delirium?

Delirium is a state of severe confusion that is usually brought on by a medical condition. It’s thought to be due to the brain producing too much dopamine and to little acetylcholine. Dopamine and acetylcholine are neurotransmitters (chemicals) that neurons (the main cells of the brain) use to communicate with each other. Nobody knows why being sick causes these chemicals to get out of balance. However, when they get out of balance people experience a typical set of symptoms called delirium.1

So what exactly are the symptoms of delirium?

The first symptom of delirium is a disturbance of consciousness (awareness) that keeps you from being able to focus (concentrate or pay attention). The second symptom involves a change in your thinking. Either you can’t remember things, you’re confused about where you’ re at, you start hallucinating, or a combination of these. People often describe this set of symptoms as “he was talking out of his head”. The third thing to remember about delirium is its time course. Delirium happens over a relatively short period of time (hours to days and not months to years like what happens in the dementia).2

Okay, that sounds like what’s happening to my dad. Now what are we going to do about it?

When someone gets delirium, there are two main things that need to be done. The first, is figuring out what caused the delirium so that it can fixed. While trying to figure out what is causing the delirium usually means laboratory and imaging tests and is best left to the doctors, you, the patient’s family, usually have information that is invaluable to correctly identifying the underlying cause. Some if this information includes:

  • How the patient typically acts at “baseline” and how different they are acting now,
  • Any recent change (either starting, stopping or changing the dose) in medications or substances they are taking
  • Any symptoms of illness they were displaying before seeing the doctor (fever, cough, trouble breathing, etc).

After we figure out and correct what is causing the delirium, we can move on to treat the symptoms of delirium.

So how exactly are you going to treat the symptoms of delirium?

Treating delirium consists of two main treatments. First, medications, (called antipsychotics) can be used to decrease the abnormally high amount of dopamine in the brain. The second “treatment” is not actually a medication but more a set of behaviors that can help make delirium resolve quicker. The National Institute for Clinical Excellence (NICE) in the United Kingdom has published a set of guidelines consisting of several behaviors we can do to help prevent delirium. Although it has not been proven to actually treat delirium once someone has it, we think that instituting these behaviors can help delirium resolve faster, or at least keep it from returning once it has resolved. Some of these behaviors need to be implemented by the healthcare team. However, many of these behaviors are simple and can be instituted by the patient’s family.

OK, I’m on board, what can I do to help?

One of the main problems with delirium that can be addressed by family members is re-orientation. That simply means reminding the patient where they’re at, what time it is, and why they’re in the hospital. Remember, people with delirium have very poor memories and sometimes need to be reminded 20, 30, 40, even 50 times in a single day. Another intervention that can be better initiated by the family than anyone else is making sure that the patient has their hearing aids, glasses, dentures, and other devices from home. Without these, patients do much worse. Other things families can do include making sure that the hospital has a list of the patient’s medications as well as helping the patient eat and move around. Patients with delirium often have trouble communicating with their healthcare providers.

Therefore, the family can help tell the healthcare team if something is wrong with the patient. Some of the conditions to watch out for and let the team know about are dehydration, constipation, trouble breathing, signs of infection, trouble walking, and pain. The last, and perhaps the most important, thing to remember about the delirium is that it gets much, much, much, worse when patients don’t sleep normally at night. Therefore, things that we can do to help patients sleep better at night include leaving the blinds open through the day, keeping the patients active and busy through the day, as well as being quiet and leaving the lights off at night.

For Psychiatrists and Clinicians

For more information about delirium, or any other psychiatric diagnoses, head on over to www.psychiatrylectures.com . There you’ll be able to access the same professionally prepared psychiatry lectures that are given to medical students, psychiatry residents, and fellow psychiatrists.

Sources

1. Sadock, Kaplan & Sadock, (2007). FULL CITATION [Sadock, B. J., Kaplan, H. I., & Sadock, V. A. (2007).Kaplan & sadock's synopsis of psychiatry. (10 ed., pp. 322-329). Lippincott Williams]

2. American Psych, A., (2000).  FULL CITATION [American Psych, A. (2000). Diagnostic and statistical manual of mental disorders, dsm-iv-tr. (4th ed. ed.). Arlington VA: American Psychiatric Publishing, Inc.]

Synopsis of the National Institute for Health and Clinical Excellence Guideline for Prevention of Delirium – Annals of Internal Medicine

About the author

Derek S Mongold MD 2012 for Healthin30

Derek S. Mongold MD

Derek S. Mongold MD completed a combined Family Medicine and Psychiatry residency at West Virginia University (WVU) School of medicine. He is board certified by the American Board of Family Medicine and the American Board of Psychiatry and Neurology and is s currently an assistant professor at the University of Virginia (UVA) health system where he directs the consultation-liaison psychiatry program. He is also the webmaster of www.psychiatrylectures.com .

 

Editor’s Note

For Health Consumers and Patients

Patient information: Delirium (Beyond the Basics) – Wolters Kluwer – Up To Date
http://www.uptodate.com/contents/delirium-beyond-the-basics

The following organizations also provide reliable health information. [ Source Patient information: Delirium (Beyond the Basics) - Wolters Kluwer – Up To Date the-basics]

National Library of Medicine
( www.nlm.nih.gov/MEDLINEPLUS/ency/article/000740.htm )
National Cancer Institute
( www.cancer.gov/cancertopics/pdq/supportivecare/delirium/Patient )
The Mayo Clinic
( www.mayoclinic.com/health/delirium/DS01064 )

Your turn

Are you a clinician who treats patients with delirium? What are the most important things clinicians and patients should be aware of? Are you a family member and caregiver? We’d love to hear from you. What has been your experience?

As always thank you for your very valuable time.

Connect with me | Stay in touch

 

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