Delirium

(Photo: psychnews.org)

Delirium, although not uncommon in individuals that are experiencing a medical emergency, have recently undergone an operation, or are elderly, is not often talked about amongst laypeople and often goes undiagnosed. Being uninformed on such acute episodes or events can cause panic in loved ones or lack of action when required. Luckily, delirium is usually transient and treatable by addressing the underlying condition that caused it.

Delirium is described well by its alternative name: acute confusional state. Delirium is a syndrome characterized by altered cognition, including abnormal functioning of attention, memory, perception, decision-making, problem-solving, and planning. These symptoms often result in illusions, delusions, hallucinations, and changes in affect and circadian rhythm. Delusions can be persecutory and cause fear and hostility, and hallucinations are usually visual, but can be auditory or tactile as well. Changes in affect may result in anxiety, apathy, anhedonia, confusion, and fear. If the condition goes untreated, the patient may suffer seizures, fall into stupor, or even result in coma or death (Brown & Boyle, 2002). Delirium predicts increased 12-month mortality after release from inpatient medical care, especially in patients without dementia (McCusker, Cole, Abrahamowicz, Primeau, & Belzile, 2002).

(Photo: Delirium pathophysiology: An updated hypothesis of the etiology of acute brain failure, onlinelibrary.wiley.com/doi/10.1002/gps.4823)

Risk factors for delirium include old age, hospitalization, having recently undergone an operation, and terminal illness (Brown, et al., 2002). Delirium is common in intensive care unit inpatients, one study suggesting that delirium affects approximately 45-87% of inpatients (Cavallazzi, et al., 2012). Delirium may be especially high in certain specialized intensive care units, as suggested in a 2010 study on burn intensive care unit patients, which found delirium to affect about 80% of patients (Agarwal, O'Neill, Cotton, Pun, Haney, Thompson, Kassebaum, Shintani, Guy, Ely, & Pandharipande, 2010). In intensive care units, a systematic review of delirium performed by Van Rompaey, B., Schuurmans, M. J., Shortridge-Baggett, L. M., Truijen, S., & Bossaert, L. (2008), identified twenty-five different risk factors. These factors include “respiratory disease, older age, alcohol abuse, and dementia” (Cavallazzi, et al., 2012), which were considered predisposing, and use of anticholinergic medications, benzodiazepines, and opioids, “electrolyte abnormalities, fever, pressor requirement, increasing opiate dose, and metabolic acidosis” (Cavallazzi, et al., 2012).

(Table: McCabe, J. J., & Kennelly, S. P. (2015). Acute care of older patients in the emergency department: strategies to improve patient outcomes.Open access emergency medicine: OAEM,7, 45., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4806806/)

Delirium can be wrongly diagnosed as functional psychosis, dementia, or even an anxiety disorder or a depressive disorder. Delirium causes disruptions in cognition and hallucinations that are not present in functional psychosis. Delirium often exhibits acute onset, fluctuations in symptoms, transient perceptual disturbances, and changes in psychomotor activity, unlike dementia, which exhibits a slow onset with progressive severity of symptoms, and rarely includes perceptual disturbances or changes in psychomotor activity (Brown, et al., 2002). Anxiety, fearfulness, anhedonia, and apathy caused by change in affect can be mistaken for anxiety or depressive disorders.

Biomarkers for delirium include high baseline levels of procalcitonin protein, enhanced anticholinergic activity in serum, and increased S100B protein, brain-derived neurotrophic factor, interleukins, cortisol, and neuron-specific enolase levels in serum (Cavallazzi, et al., 2012).

Despite the serious consequences of delirium, many cases go unnoticed. Whether it be from complications of the underlying cause of the syndrome or from injuries resulting from delirium’s effect on the patient’s consciousness and cognitive abilities, delirium can lead to major physical or cognitive impairment. Inpatient falls in hospitals are associated with delirium (Lakatos, B. E., Capasso, V., Mitchell, M. T., Kilroy, S. M., Lussier-Cushing, M., Sumner, L., Repper-Delisi, J., Kelleher, E.P., Delisle, L.A., Cruz, C. & Stern, T. A., 2009). Studies suggest that delirium goes undiagnosed in patients approximately 24% of the time (Cavallazzi, Saad, & Marik, 2012). A major factor in the failure to diagnose delirium is the societal expectation of older people to operate at lower cognitive levels. Some believe that it is normal for an older adult to experience altered levels of consciousness in everyday life, but being of older age is not necessarily coupled with major declines in cognitive health. Many older adults are highly functioning, yet even some in the medical field may carry this unconscious bias. This may lead to failure to report behavior that would otherwise be considered abnormal in younger patients, simply due to their age. Abnormal behavior, irritability, and confusion could be a symptom of an underlying condition and requires further evaluation. If such symptoms are considered abnormal in a younger patient, it is important that they are treated as such in older patients as well. It is important to obtain information from third parties that are knowledgeable about the patient’s usual behavior and level of functioning for reference.

(Photo: shutterstock.com)

In nursing home settings, overmedication of elderly, or chemical restraint, with antipsychotics, is a common practice. A study performed in nursing homes all over the US in 2010 found that over 17% of patients in assisted living facilities were administered antipsychotic medication in excess daily (U.S. Centers for Medicare & Medicaid Services, 2012). Medications should be administered on a schedule, not “as needed” unless the patient poses a serious danger to themself or others. This is a problem that needs to be addressed at many assisted living facilities, as many such institutions overmedicate older adults so that they remain seated or supine, and therefore require little to no care or supervision. Not only is this an encroachment on the rights of patients, but it is hazardous to their health, can worsen delirium and its underlying cause, and may lead to increased tolerance of medications, thereby making medications less effective when they are required. This also increases side effects and the possibility of organ damage. The possible negative effect of antipsychotic use may include cardiovascular complications, pulmonary embolism, hematological complications, gastrointestinal effects, liver failure, pancreatitis, seizures, neuroleptic malignant syndrome, rhabdomyolysis, type 2 diabetes mellitus, interstitial nephritis, and interstitial lung disease (Manu, Flanagan, & Ronaldson, 2016).

(Photo: Rothbard, G. (2018). Comparison of Antipsychotic Drugs to Prevent Rehospitalization in Schizophrenia. Psychiatry Advisor.)

There is also question as to whether antipsychotic use in delirium is effective at all. Some studies find improvement in delirium symptoms (Agar, Lawlor, Quinn, Draper, Caplan, Rowett, Sanderson, Hardy, Le, Eckermann, & McCaffrey, 2017; Devlin, Roberts, Fong, Skrobik, Riker, Hill, Robbins, & Garpestad, 2010; Lonergan, Britton, & Luxenberg, 2007), however, others report no difference in symptom improvement or quality of life between delirium patients given antipsychotics and the placebo group (Al-Qadheeb, Skrobik, Schumaker, Pacheco, Roberts, Ruthazer, & Devlin, 2016; Girard, Exline, Carson, Hough, Rock, Gong, Douglas, Malhotra, Owens, Feinstein, & Khan, 2018; Girard, Pandharipande, Carson, Schmidt, Wright, Canonico, Pun, Thompson, Shintani, Meltzer, & Bernard, 2010). A 21-day randomized, placebo-controlled trial (2010) in which patients were treated with haloperidol, ziprasidone, or a placebo found no significant difference in number of days spent alive without delirium or coma, number of days spent without the need for a ventilator, length of hospital stay, and mortality. Both the haloperidol and ziprasidone groups experienced similar levels of extrapyramidal symptoms, and more patients that received haloperidol experienced akathisia (Girard, et al., 2010), a movement disorder that causes restlessness, an urge to move, and in severe cases, aggression and suicidal thoughts. Other studies suggest that haloperidol, a typical antipsychotic that is considered standard for treatment of delirium, is associated with increased extrapyramidal symptoms. Another study found that in patients that had previously undergone operation, low doses of haloperidol were associated with decreased severity and duration of delirium, but did not affect the incidence of delirium, and high doses were associated with increased side effects, such as parkinsonism, as opposed to atypical antipsychotics (Lonergan, et al., 2007). One randomized clinical trial that tested the efficacy of oral haloperidol and risperidone compared to placebo in delirium symptoms of patients receiving palliative care, reported lower overall survival in patients treated with haloperidol compared to the placebo group (Agar, et al., 2017).

(Photo: Dana Neely, Getty Images)

Delirium is a common syndrome in hospital inpatients and elderly patients that causes alterations in cognition and perception and denotes a medical emergency. Failure to diagnose delirium is a common but serious occurrence and poses a large problem in the medical field. Failure to treat the underlying condition that causes delirium can lead to worsening of symptoms and the underlying condition, which can lead to further health complications and potential death. The standard treatment for delirium is with antipsychotic medication, however, patients are frequently overmedicated and may suffer many negative health outcomes from the medication. Some question the efficacy of antipsychotic medication in the first place; many studies show antipsychotic medication to be ineffective or even more detrimental than beneficial. Medical providers need to be constantly aware of each patients’ cognitive functioning, antipsychotic administration needs to be properly dosed, especially in assisted living facilities, and new treatments or different antipsychotics need to be further investigated for safety and efficacy.

Sources

Agar, M. R., Lawlor, P. G., Quinn, S., Draper, B., Caplan, G. A., Rowett, D., Sanderson, C., Hardy, J., Le, B., Eckermann, S. & McCaffrey, N. (2017). Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care: a randomized clinical trial. JAMA internal medicine, 177(1), 34-42.

Agarwal, V., O'Neill, P. J., Cotton, B. A., Pun, B. T., Haney, S., Thompson, J., Kassebaum, N., Shintani, A., Guy, J., Ely, E. W., & Pandharipande, P. (2010). Prevalence and risk factors for development of delirium in burn intensive care unit patients. Journal of burn care & research, 31(5), 706-715.

Al-Qadheeb, N. S., Skrobik, Y., Schumaker, G., Pacheco, M., Roberts, R., Ruthazer, R., & Devlin, J. W. (2016). Preventing ICU Subsyndromal Delirium Conversion to Delirium with Low Dose IV Haloperidol: A Double-Blind, Placebo-Controlled Pilot Study. Critical care medicine, 44(3), 583.

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Devlin, J. W., Roberts, R. J., Fong, J. J., Skrobik, Y., Riker, R. R., Hill, N. S., Robbins, T. & Garpestad, E. (2010). Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study. Critical care medicine, 38(2), 419-427.

Girard, T. D., Exline, M. C., Carson, S. S., Hough, C. L., Rock, P., Gong, M. N., Douglas, I. S., Malhotra, A., Owens, R. L., Feinstein, D. J. & Khan, B. (2018). Haloperidol and ziprasidone for treatment of delirium in critical illness. New England Journal of Medicine, 379(26), 2506-2516.

Girard, T. D., Pandharipande, P. P., Carson, S. S., Schmidt, G. A., Wright, P. E., Canonico, A. E., Pun, B. T., Thompson, J. L., Shintani, A. K., Meltzer, H. Y. & Bernard, G. R. (2010). Feasibility, efficacy, and safety of antipsychotics for ICU delirium: the MIND randomized, placebo-controlled trial. Critical care medicine, 38(2), 428.

Lakatos, B. E., Capasso, V., Mitchell, M. T., Kilroy, S. M., Lussier-Cushing, M., Sumner, L., Repper-Delisi, J., Kelleher, E. P., Delisle, L. A., Cruz, C. & Stern, T. A. (2009). Falls in the general hospital: association with delirium, advanced age, and specific surgical procedures. Psychosomatics, 50(3), 218-226.

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McCusker, J., Cole, M., Abrahamowicz, M., Primeau, F., & Belzile, E. (2002). Delirium predicts 12-month mortality. Archives of internal medicine, 162(4), 457-463.

U.S. Centers for Medicare & Medicaid Services. (2012). CMS Announces Partnership to improve dementia care in nursing homes. U.S. Centers for Medicare & Medicaid Services.

Van Rompaey, B., Schuurmans, M. J., Shortridge-Baggett, L. M., Truijen, S., & Bossaert, L. (2008). Risk factors for intensive care delirium: a systematic review. Intensive and Critical Care Nursing, 24(2), 98-107.