Delirium Part 2 of 3 Parts


How Common is Delirium?


Delirium is extremely common in hospitalized older adults. One third of general medical patients who are 70 years of age or older have delirium; the condition is present in half of these patients on admission and develops during hospitalization in the other half. Oct 12, 2018

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5706782/#:~:text=Delirium%20is%20extremely%20common%20in,hospitalization%20in%20the%20other%20half.


Delirium is very common in intensive care units and on cancer wards, but can be found on any ward throughout the hospital and in nursing homes and can appear in private homes, especially in high-risk patients.

https://www.uptodate.com/contents/delirium-beyond-the-basics


“Hospital delirium” can affect 10% to 30% of…patients.

https://my.clevelandclinic.org/health/diseases/15252-delirium


Causes of Delirium


It is not clear why or how delirium develops. There are many potential causes, with the most common including infections, medications, and organ failure (such as severe lung or liver disease).


A urinary tract infection or dehydration can cause delirium in certain people.


The time after surgery (called the postoperative period) is a common time for delirium to develop, especially in older people. This may be related to pain or the use of anesthesia or pain medications. https://www.uptodate.com/contents/delirium-beyond-the-basics


There are many different problems that can cause delirium:

· Alcohol or drugs, either from intoxication or withdrawal

· Dehydration and electrolyte imbalance

· Dementia

· Hospitalization, especially in intensive care

· Infections, such as urinary tract infections, pneumonia, and the flu

Medicines. This could be a side effect of a medicine, such as sedatives or opioids. Or it could be withdrawal after stopping a medicine.

· Metabolic disorders

· Organ failure, such as kidney or liver failure

· Poisoning

· Serious illnesses

· Severe pain

· Sleep deprivation

· Surgeries, including reactions to anesthesia

https://www.uptodate.com/contents/delirium-beyond-the-basics


Delirium is usually triggered by a medical illness, or by the stress of hospitalization, especially if the hospitalization includes surgery and anesthesia. https://betterhealthwhileaging.net/what-is-delirium-10-things-to-know/


Delirium occurs when signals in the brain aren't sent and received properly.

https://www.mayoclinic.org/diseases-conditions/delirium/symptoms-causes/syc-20371386#:~:text=Any%20condition%20that%20results%20in,who%20live%20in%20nursing%20homes.


Hospital stays often involve room changes, invasive procedures, loud noises, and poor lighting. Lack of natural light and lack of sleep can make confusion worse. https://www.mayoclinic.org/diseases-conditions/delirium/symptoms-causes/syc-20371386#:~:text=Any%20condition%20that%20results%20in,who%20live%20in%20nursing%20homes.


Is delirium a disease? No, delirium is not a disease. It’s a changed mental state.

https://my.clevelandclinic.org/health/diseases/15252-delirium


There often isn’t a single cause for delirium. Instead, it tends to happen due to a combination of triggers (illness, pain, medication side-effects) and risk factors (dementia, or pre-dementia). https://betterhealthwhileaging.net/hospital-delirium-what-to-do/#:~:text=Delirium%20is%20a%20state%20of,Alzheimer's%20or%20another%20dementia%20diagnosis.


What Causes Delirium in Children?


· A severe burn or other serious injury

· Underlying new or chronic illness, including, seizures, infections, a very high fever, and/or problems with the thyroid or adrenal glands.

· Adverse effects of medications

· Anesthesia, referred to as emergence delirium

· Head injury

· Disruption of the sleep-wake cycle

· Not enough oxygen to the brain

· Major surgery

· Poisoning

· Electrolyte imbalances

https://www.nationwidechildrens.org/conditions/delirium#:~:text=What%20Causes%20Delirium%20in%20Children,the%20thyroid%20or%20adrenal%20glands


Delirium and Dementia


Delirium mostly affects a person’s attention. Dementia affects memory.


Delirium is a temporary state that begins suddenly. Dementia is chronic (long-term) confusion that usually begins gradually and worsens over time.

https://my.clevelandclinic.org/health/diseases/15252-delirium


…dementia is the most common risk factor for delirium, and two-thirds of cases of delirium occur in people who already have dementia. https://www.healthinaging.org/a-z-topic/delirium/causes

…delirium [is] a sudden disruption of consciousness and cognition marked by vivid hallucinations, delusions, and an inability to focus that affects 7 million hospitalized Americans annually. The disorder can occur at any age — it has been seen in preschoolers — but disproportionately affects people older than 65 and is often misdiagnosed as dementia. While delirium and dementia can coexist, they are distinctly different illnesses.

https://khn.org/news/for-many-patients-delirium-is-a-surprising-side-effect-of-being-in-the-hospital/ “For Many Patients, Delirium Is A Surprising Side Effect Of Being In The Hospital,”

by Sandra G. Boodman, June 2, 2015


Delirium is a state of worse-than-usual mental function, brought on by illness or some kind of stress on the body or mind. Although people with dementia are especially prone to develop delirium, delirium can and does affect many aging adults who don't have Alzheimer's or another dementia diagnosis. https://betterhealthwhileaging.net/hospital-delirium-what-to-do/#:~:text=Delirium%20is%20a%20state%20of,Alzheimer's%20or%20another%20dementia%20diagnosis.


Symptoms of Delirium


Delirium is not a disease, but rather a group of symptoms.


There are abnormal changes in the person's level of consciousness and thinking. The person may be sleepy, or may appear to be withdrawn and depressed (hypoactive delirium) or agitated (hyperactive delirium), or alternate between these states. The changes may be subtle initially.


The person often has difficulty maintaining focus. He/she may change the subject frequently in a conversation, have difficulty retaining new information, mention strange ideas, or be disoriented (in place or in time). Some patients have visual hallucinations.


These changes develop over a short period of time (hours to days) and tend to become intermittently worse, especially in the afternoon and evening. This sudden change helps to differentiate delirium from dementia, which worsens slowly over months to years.

https://www.uptodate.com/contents/delirium-beyond-the-basics


Symptoms often come and go during the day. There may be periods of no symptoms. Symptoms tend to be worse at night when it's dark and things look less familiar. They also tend to be worse in settings that aren't familiar, such as in a hospital. https://www.mayoclinic.org/diseases-conditions/delirium/symptoms-causes/syc-20371386#:~:text=Delirium%20is%20a%20serious%20change,to%20one%20or%20more%20factors.


Symptoms…include:


· Changes in alertness (usually more alert in the morning, less at night)

· Changing levels of consciousness

· Confusion

· Disorganized thinking, talking in a way that doesn't make sense

· Disrupted sleep patterns, sleepiness

· Emotional changes: anger, agitation, depression, irritability, overexcitement

· Hallucinations and delusions

· Trouble concentrating

· Memory problems, especially with short-term memory

https://medlineplus.gov/delirium.html


Delirium exists as a stage of consciousness somewhere in the spectrum between normal awakeness/alertness and coma. While requiring an acute disturbance in consciousness/attention and cognition, delirium is a syndrome encompassing…poor attention/vigilance (100%), memory impairment (64–100%)…disorientation (43–100%), acute onset (93%), disorganized thinking/thought disorder (59–95%)…delusions (18–68%), and perceptual change/hallucinations (17–55%). https://en.wikipedia.org/wiki/Delirium


“Structural Brain Changes in Delirium: An Integrative Review”


By Laura Beth Kalvas, BSN, RN, PCCN1 and Todd B. Monroe, PhD, RN-BC, FNAP, FGSA, FAAN1


“We examined the volume and quality of available evidence to answer the following question: What structural changes are occurring in the adult brain during delirium?


Commonly noted structural abnormalities [in the brain] were impaired white matter integrity, brain atrophy, ischemic lesions, edema, and inflammation. Findings demonstrated widespread alterations in several brain structures [during and after the Delirium event?].


Delirium is a serious complication of acute illness that affects approximately 50% of hospitalized older adults (Hshieh, Inouye, & Oh, 2018) and up to 87% of patients in the intensive care unit (ICU; Cavallazzi, Saad, & Marik, 2012). Defined in the Diagnostic and Statistical Manual of Mental Disorders as a fluctuating change in mental status, delirium is characterized by a disturbed level of consciousness with a reduced ability to focus and either (a) a change in cognition or (b) the development of a perceptual disturbance. (American Psychiatric Association, 2013)


[perceptual disturbance: a disorder of perception, such as (a) recognizing letters but not words, (b) inability to judge size or direction, (c) confusing background with foreground, (d) inability to filter out irrelevant sounds or sights, (e) a body-image distortion, or (f) difficulty with spatial relationships (e.g., misperceiving the difference between a straight line and a curved line). Also called perceptual disorder.] https://dictionary.apa.org/perceptual-disturbance


…research has given little consideration to the pathologic brain changes associated with delirium. Although neuroimaging has been suggested as a noninvasive method for studying both structural (damage to brain structures) and functional (damage to the communication within and between brain structures) brain abnormalities, the method is underutilized in nursing research (Monroe et al., 2017)


Neuroimaging found evidence of associations between delirium and cortical atrophy and white matter lesions but could not exclude age and cognition as covariates. [The question is which came first: delirium or brain anomalies? Did one cause the other?]


‘In the current review, we excluded studies that only used neuroimaging prior to delirium, as the focus here is on structural alterations that could be directly associated with the experience of delirium.


Neuroimaging is a noninvasive method that is useful for understanding changes occurring in the brain during delirium.


Research has shown widespread damage, including atrophy and impaired white matter integrity, in the frontal, temporal, parietal, and limbic systems of patients who experience delirium. These alterations persist for 3–5 months after discharge (Gunther et al., 2012; Morandi et al., 2012; Rolandi et al., 2018), further highlighting the possible link between long-term cognitive impairment and delirium.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6794667/

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