Delirium

Delirium, also known as acute confusional condition, is a naturally occurring fall in cognitive function from a previously reached baseline level. It is characterized by an erratic course, attentional impairments, and significant generalized behavioral disarray. Other cognitive deficiencies, alterations in arousal (hyper, hypo, or mixed), perceptual abnormalities, a disturbed sleep-wake cycle, and psychotic characteristics including hallucinations and delusions are frequently present.

Delirium is a clinical phenomenon rather than a disease (a set of symptoms). It can be brought on by an underlying illness, medications used to treat that illness during a key phase, drug withdrawal, a new mentation issue, or different combinations of two or more of these variables. It follows from the criterion that a delirium diagnosis is typically impossible to make without first determining the patient's baseline level of cognitive function. In other words, one would anticipate a mentally ill or demented person who is functioning at their own baseline level of mental capacity to appear delirious in the absence of a baseline mental functional condition to compare their state to.

Features:

• Alterations in consciousness (that is, reduced clarity of awareness of the environment, with reduced ability to focus, sustain, or shift attention).
• Changes in cognition (such as memory loss or difficulty understanding problems) or perceptual disturbances (hallucination).
• Beginning of hours to days, and propensity to change.
• Behavior may be either excessively or insufficiently active, and sleep is frequently interrupted due to a disruption of the circadian rhythm.
• The substance is frequently sophisticated, yet thinking is slow and clumsy.

Causes

Predisposing factors:

• Older age
• Cognitive impairment / dementia
• Physical comorbidity (biventricular failure, cancer, cerebrovascular disease)
• Psychiatric comorbidity (e.g., depression)
• Sensory impairment (vision, hearing)
• Functional dependence (e.g., requiring assistance for self-care and/or mobility)
• Dehydration / malnutrition
• Drugs and drug-dependence.
• Alcohol dependence

Precipitating factors:

• Metabolic
• Malnutrition
• Dehydration, electrolyte imbalance
• Anaemia
• Hypoxia
• Hypercapnoea
• Hypoglycaemia
• Endocrine disorders (e.g., SIADH, Addison’s disease, hyperthyroidism, hypercalcaemia)
• Infection
• Especially respiratory and urinary tract infections
• Medication
• Anticholinergics, dopaminergic, opioids, steroids, recent polypharmacy
• Vascular
• Stroke/Transient ischaemic attack
• Myocardial infarction, arrhythmias, decompensated heart failure
• Physical/psychological stress
• Pain
• Iatrogenic event, esp. post-operative, mechanical ventilation in ICU
• Chronic/terminal illness, esp. cancer
• Post-traumatic event (e.g., fall, fracture)
• Immobilisation/restraint
• Severe constipation/fecal impaction
• Urinary retention
• Other
• Substance withdrawal (esp. alcohol, benzodiazepines)
• Substance intoxication
• Traumatic head injury

Symptoms

• Decreased sensitivity to the environment.
• A difficulty to switch topics or maintain attention on one.
• Being unable to react to inquiries or conversation in favor of becoming hooked on an idea.
• Being susceptible to distraction from insignificant things.
• Being reclusive, with little or no activity or reaction to the surroundings.
• Poor ability to think (cognitive impairment).
• Especially with regard to recent events, poor memory.
• For instance, being disoriented means not knowing who or where you are.
• Having trouble pronouncing or remembering words.
• Talk that is nonsensical or rambling.
• Difficulty comprehending speech.
• Reading or writing challenges.
• A change in behavior.
• Observing fictitious objects (hallucinations)
• Agitation, agitation, or aggressive conduct
• Creating noises such as cries, moans, or other noises
• Being reserved and silent, particularly in older adults
• Suggishness or lassitude
• Disturbed patterns of sleep
• Reversed day-night cycle of sleep and wakefulness
• Psychological disturbances
• Fear, trepidation, or paranoia
• Depression
• Easily irritated or angry
• A feeling of being happy (euphoria)
• Apathy
• Rapid and erratic mood swings
• Behavioral shifts
• Reading or writing challenges.
• A change in behavior.

Types of delirium

There are three types of delirium:

• Hyperactive delirium: 
  • This form, which is probably the easiest to identify, can involve hallucinations, agitation, pacing, restlessness, and rapid mood swings.
• Hypoactive delirium: 
  • Inactivity or decreased motor activity, sluggishness, unusual sleepiness, or appearing confused are examples of this.
• Mixed delirium: 
  • Both hyperactive and hypoactive symptoms fall under this category. The individual may abruptly shift between hyperactive and hypoactive phases.

Diagnosis

• History
• Physical examination
• Mental status examination
• Investigation as related to causative factors

Management

• Antipsychotic medications in low doses may be used to manage the patient.
• Example of determining the reason and immediately fixing it 100 mg of vitamin B1 IV for thiamine deficiency, 50 mg of 50% dextrose IV for hypoglycemia, oxygen for hypoxia, and IV fluids for fluid and electrolyte imbalance.
• The best way to treat a patient who is experiencing alcohol and sedative withdrawal symptoms is with a benzodiazepine either orally, intramuscularly, or slowly intravenously.
• IV diazepam 10 mg slowly if the patient is really ecstatic.
• Support for the patient's family and on an emotional level.

Nursing management

• Limit environment stimulation and maintain peace and quiet in the unit.
• There should always be a comforting and supportive presence beside the patient's bedside.
• The patient may need to be physically restrained if they are agitated.
• Take away any items from the space that might be contributing to perceptions that aren't accurate.
• To guarantee safety while engaging in these activities, provide close supervision.
• Keep the same person by the patient's bedside as much as you can.
• Speak to a client calmly, clearly, and in a quiet voice while utilizing short sentences.
• Make sure the space is well-lit, especially at night.
• After the physical examination, the patient should receive the proper care, such as using the right nursing techniques to lower a high fever.
• Maintain the input and outflow charts, provide oral and skin care, and keep an eye on your vital indicators.
• Tell the patient again where he is and what day, time, and date it is.
• Even if the patient misidentifies the people, introduce them by name.
• Tell him what day it is and place a calendar in the room. Techniques for reorienting yourself or remembering triggers like clocks, calendars, and family photos may be useful.
• Using eyeglasses and hearing aids, if necessary, to treat sensory impairments
• Never let these patients depart unaccompanied or alone.