Delirium: Species, Symptoms and Treatment

Delirium is one of the most common types of obscuration of consciousness. This transient mental disorder has an exogenous nature and develops as a result of functional disorders of the brain in the presence of severe intoxication and diseases. Therefore, the treatment of delirium is directed not only to the relief of the main psychotic symptoms, but also to the correction of primary disorders.

Etiology and pathogenesis

The cause of delirious state development is neuronal dysfunction associated with hypoxia, dysmetabolic and toxic damage to nervous tissue. In this process, the cortex and major subcortical structures are involved. Moreover, the pathogenesis is based not on structural changes, but on the imbalance of neurotransmitters, the slowing down of the work of neurons and the speed of inter-neuronal transmission.

Neurophysiological studies show that the greatest role in the development of delirium is given to the cholinergic deficit and the general pathological response to stress and neuroinflammation. But the death of small groups of cells that have undergone critical ischemia or massive toxins is not excluded.

Conditions that most often contribute to the development of delirium:

• brain hypoxia due to cerebral vascular accident of medium and small caliber, with cardiovascular disease decompensation;
• systemic infections, especially accompanied by fever and severe general intoxication;
• infections of the central nervous system, with the key moments of pathogenesis is the swelling of the nervous tissue and toxic damage to the cerebral vessels;
• withdrawal syndrome for drug and alcohol dependence;
• exogenous intoxications of non-alcoholic genesis, including those caused by the intake of psychotropic and non-psychotropic drugs and their combination;
• chronic ischemic disease of the brain in the stage of decompensation;
• decompensation of severe cardiovascular diseases and other somatic pathologies;
• postoperative period, especially in the case of general anesthesia;
• severe endocrinopathies.

Predisposing factors are old age, dehydration, the presence of a complex of chronic diseases, the need for simultaneous reception of various drugs, the general weakness of the patient. But in the presence of serious infections, delirium can develop in a previously healthy person.

The main signs of delirium

The main manifestation of delirium are hallucinations.

Delirium has all the characteristic signs of obscuration of consciousness: detachment with a significant difficulty of perception of the surrounding world and subsequent amnesia, a violation of the thought process and orientation. Allopsychic disorientation is not typical. In addition, delirium is characterized by hallucinatory and illusory disorders. Their content determines the behavior of the patient and often causes the development of sensual delusions.

The appearance of hallucinations is preceded by illusory and parodolic disturbances, frightening dreams. A little later they are supplemented with hypnagogic( emerging in the state of solitary) hallucinations. And at the stage of unfolded delirium hallucinations become abundant, scenic and almost constant. Their influx can be provoked by pressing on the eyeballs, which is called Lipman's symptom.

Delusions hallucinations are true. They are subjectively indistinguishable from the objects of the surrounding world and are therefore perceived by man as real images, even if their content is clearly fantastic. Optical hallucinations predominate - abundant, bright, detailed, most often unpleasant and intimidating. But auditory, tactile and olfactory deceptions are also possible.

Hallucinatory experiences are accompanied by a tense affect of anxiety and fear. There are periods of psychomotor agitation or hypodynamia. In an attempt to defend himself or run away, the patient often presents a danger to others and himself. But with some forms of delirium, motor anxiety is limited to the bedside, and there is no apparent affect of anxiety. Most often this indicates a deep disintegration of mental activity and is a sign of severe brain suffering.

Productivity of contact with the patient, severity of disorientation and presence of amnesia after relief of delirium depend on the degree of confusion of consciousness and the volume of perception of the surrounding world. Memories of the real events that occurred in this period are fragmentary or completely absent, there is also a partial or complete amnesia of their experiences.

Deployment phases of delirium

In a state of delirium, patients can be extremely aggressive, trying to get rid of their visions.

Delirium does not refer to paroxysmal developing states. It is characterized by staging and certain patterns in the appearance of symptoms. The classical delirium has 4 stages of development, and its deployment can stop at any stage. It depends on the severity of the existing metabolic disorders, the number of affected neurons and the functional reserves of the brain. With timely treatment, a delirium can be broken even before the development of obvious hallucinatory-delusional disorders. Prolonged deep sleep can also contribute to the patient's exit from the state of darkened consciousness.

At the first stage of the delirium, the associative component of thinking, the influx of associations and vivid sensual memories, and loquaciousness are amplified and accelerated. Attention is easily distracted, because of which statements become inconsistent and sketchy. Affect is changeable, criticality is reduced, the orientation is not always clear, but the tips are productive. Sleep becomes superficial, with disturbing, bright and not always distinguishable from reality dreams. It does not bring a sense of rest and is accompanied by a disturbance in the sleep-wake cycle. These symptoms are called precursors.

The second stage is the deepening of existing disorders with the appearance of visual illusions and pareidoles, which even intensify when they are viewed by the patient. Hypnagogic hallucinations are also noted. Increases hyperesthesia, aggravated violations of attention, worsening perception of the real environment. There is a flickering of the level of consciousness, which at deeper stages of delirium will lead to the appearance of lucid windows. Disorientation is growing, first of all the exact definition of time suffers.

The third stage is an abundance of true hallucinations, absorbing the patient's attention and often leading to the development of sensual delirium. Deceptions of perception can take a stsenopodobny character and combine with each other, although the prevailing are the visual images. There are marked violations of behavior, so that the patient often presents a danger to themselves and others. He can run, jump out of the window, go out onto the roadway, manifest physical aggression, while not correlating his actions with the real situation. Sleep is short, falling asleep is usually shifted to early morning hours. Contact with the patient is unproductive, his disorientation in space and time is noted.

What is the delirium of

? There are several varieties of delirium, each of them has its own peculiarities. This takes into account the type of flow, the severity of individual symptoms and the etiologic factor.

The main types of delirious unconsciousness:

• typical( classical) delirium;
• hypokinetic variant;
• abortive delirium, its variant is "delirium without delirium" - a brief episode of allopsychic disorientation without the development of a hallucinatory symptomatic;
• is a mutating delirium;
• professional delirium.

In hypokinetic delirium, the patient has no obvious behavioral disorders, despite the presence of actual illusory-hallucinatory disorders. There is even a decrease in motor activity, which can lead to a more severe course of the underlying disease and an increased risk of a fatal outcome in the postoperative period. In addition, such delirium can be mistaken for asthenia or a depressed state.

The muttering( mutating) variant is considered by some experts as the fourth, the deepest, delirium stage. At the same time, mental activity is disintegrated, external stimuli do not attract the patient's attention. He is immersed in experiences, incoherently mumbling. Motor anxiety is limited to the outside of the bed, the movements are not targeted and are combined with athetozopodobnymi and choreiform kerkinezes. There is a symptom of "robbery", when a person seems to take off his thread or hair, grabs small items, pulls on bed linens and clothes. Often patients in this condition tear the sheets on the flaps, unscrew the buttons, make holes in the mattresses with their fingers.

After exiting from muttering delirium, full amnesia of this pathological episode is noted. The development of such a confusion of consciousness against the background of severe somatic diseases is considered a threatening sign and usually indicates the presence of pronounced and sometimes critical dysmetabolic disorders.

Professional delirium also refers to severe forms of obscuration of consciousness. The patient does not have obvious signs of actual hallucinatory-delirious symptoms. A violation of behavior is the stereotyped repetition of movements associated with professional activities. The patient can simulate typing on the keyboard, sewing, knitting, working on machine tools and performing many other motor complexes. It is believed that their appearance is due not to a false orientation, but to activation in the brain responsible for automating the habitual movements of the inter-neural connections.

Separately distinguish alcoholic delirium, called in everyday life white fever. It develops in the withdrawal period a few days after the break in the drinking-bout and has its own characteristics. Hallucinations in alcoholic delirium are often characterized as micro-zoopsy( vision of small animals), often the patient also "sees" drinking companions or other people.

Often variants of white fever are hypnagogic delirium( with predominant hypnagogic hallucinations) and delirium with pronounced verbal hallucinations.

Principles of treatment

Treatment of a patient in a delirious state should be comprehensive. The scope of the activities is determined taking into account the etiology and clinical picture. And when prescribing medications try to avoid excessive sedation during the day, exacerbation of somatic pathology and early development of specific complications.

Treatment of delirium may include:

• correction of all available clinically relevant metabolic disorders;
• maintenance of adequate water balance;
• fight against infection and its toxic intoxication;
• measures to stabilize the cardiovascular system, reduce the severity of hepatic and renal failure;
• detoxification and the use of specific antidotes for poisoning;
• improvement of blood supply to the brain( with signs of cerebral ischemia);
• use of antipsychotic( neuroleptic) drugs to quickly relieve most of the symptoms of delirium;
• administration of benzodiazepine-type drugs that provide anxiolytic, sedative, nonspecific anticonvulsant and hypnotic( hypnotic) action.

The use of antipsychotic drugs for prophylactic purposes is currently considered inappropriate. To prevent the deployment of delirium, it is recommended that the somatic state of patients be corrected in a timely manner, and measures taken to reduce postoperative stress. It is also important to reduce the number of external stimuli and control the maintenance of adequate sleep-wakefulness.

Delirium itself is not a life threatening condition, but its development often serves as a sign of pronounced decompensation of severe somatoneurological pathology, which requires special attention to such a patient.