Delirium

This article covers the condition - see Delirium (disambiguation) for other meanings .

Classification according to ICD-10
F05	Delirium, not caused by alcohol or other psychotropic substances, delirium not superimposed on dementia. Incl. exogenous reaction type, organic brain syndrome, psycho-organic syndrome, psychosis in the case of infectious disease, state of confusion (not alcohol-related)
F05.1	Delirium in dementia
F05.8	Other forms of delirium: mixed aetiological delirium, postoperative delirium
F05.9	Delirium, unspecified
F10.4	Mental and behavioral disorders due to alcohol: Withdrawal syndrome with delirium
F11.4	Mental and behavioral disorders due to opioids: withdrawal syndrome with delirium
F12.4	Mental and behavioral disorders due to cannabinoids: withdrawal syndrome with delirium
F13.4	Mental and behavioral disorders caused by sedatives or hypnotics: withdrawal syndrome with delirium
F14.4	Mental and behavioral disorders due to cocaine: withdrawal syndrome with delirium
F15.4	Mental and behavioral disorders from other stimulants, including caffeine: withdrawal syndrome with delirium
F16.4	Mental and behavioral disorders due to hallucinogens: withdrawal syndrome with delirium
F17.4	Mental and behavioral disorders due to tobacco: withdrawal syndrome with delirium
F18.4	Mental and behavioral disorders due to volatile solvents: withdrawal syndrome with delirium
F19.4	Mental and behavioral disorders due to multiple substance use and consumption of other psychotropic substances: withdrawal syndrome with delirium
ICD-10 online (WHO version 2019)

The delirium , Latin Delirium ( Latin delirium , outdated, insanity '; of lira , furrow in Ackerbeet' delirare be, get out of the rut ', deviate from the straight line', 'crazy' - plural: delirium or Deliria ) is an acute state of confusion and describes an aetiologically unspecific organic brain psychosyndrome that is a life-threatening condition. According to Schüttler, delirium is an acute, physically justifiable psychosis.

Synonyms and Similar Syndromes

Delirant syndrome , sudden or acute confusion, organic psychosyndrome , acute exogenous reaction type ( Karl Bonhoeffer 1914), transit syndrome (Wieck 1961; obsolete synonym).

history

At the beginning of the 18th century Georg Ernst Stahl described the actual ("idiopathic") mental illnesses as delirium and those that occur in the company of other physical illnesses as "sympathetic delirium". He also divided into libidinal (for example hypersexuality , nymphomania and hysteria ), melancholic and feverish delirium.

Symptoms and ailments

The criteria in the tenth edition of the International Classification of Diseases (ICD-10) for the presence of delirium are:

• Disturbance of consciousness and attention
• Cognitive disorder (memory, orientation)
• Psychomotor disorders
• sleep disorders
• Acute onset and fluctuating course
• Evidence of an organic basis

In the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), delirium is defined using the following criteria:

• Disturbance of consciousness and attention
• Changes in perception (memory, orientation, language, perception)
• Acute onset and fluctuating course
• Presence of a medical disease factor

According to Lipowski (1990), delirium is an acute , severe, in principle reversible, organically caused psychosyndrome with impaired consciousness. The acute mental disorder either has an organic cause or arises from drug effects or drug withdrawal .

In addition to the disturbance of consciousness, delirium is characterized by a disturbance of attention , perception, thinking , cognition , memory , psychomotor and emotionality. A clear daily fluctuation of the symptoms is characteristic. In the case of fully developed delirium, there is often a disruption of the sleep-wake rhythm .

Other symptoms can include a reduction in abstract thinking , concentration , impaired short-term memory and disorientation . Often optical hallucinations , delusions , motor restlessness and fidgeting movements as well as affective symptoms such as depression and fear , but also euphoria or irritability and agitation (pathological restlessness) can be observed.

Based on the symptoms, a clinical distinction is made between two types of conciseness, hyperactive and hypoactive delirium. The latter is more difficult to diagnose because of the less characteristic symptoms. There are mixed forms with proportions of both types.

Test procedure

There are the following validated test methods for detecting delirium:

• CAM-ICU
• ICDSC
• Nu-DESC
• 3D CAM
• CAM-S

The Confusion Assessment Method for the ICU (CAM-ICU) was specially developed for use in an intensive care unit. Using test questions, the presence of attention, consciousness and thinking disorders is examined. The CAM-ICU is considered to be the most reliable score for detecting delirium in intensive care patients. It has a sensitivity of 0.79 and a specificity of 0.97. The Intensive Care Delirium Screening Checklist examines the state of consciousness, attention, orientation, hallucination, agitation, language, sleep and symptoms. There is a point for each symptom present. The Nursing Delirium Screening Scale (Nu-DESC) examines orientation, behavior, communication, hallucination, and psychomotor retardation. Depending on the level, there are 0 to 2 points. The procedure can also be used by trained nursing staff. The 3-minute Diagnostic Interview for CAM-defined delirium (3D-CAM) is designed for a quick assessment of a delirious state. Attention, consciousness and thinking disorders are determined on the basis of test questions. With the Confusion Assessment Method - Severity (CAM-S), the severity of a delirium is determined by recording the course, attention, thinking, level of consciousness, orientation, memory, psychomotor agitation, retardation and sleep. Point values ​​from 0-2 are assigned to the individual categories and then the sum is formed.

causes

Since delirium can be based on different diseases, the following etiologies should be considered for the differential diagnosis :

• central nervous diseases ( vascular diseases, bleeding, tumors , traumatic brain injury , epilepsy , meningitis , encephalitis , migraine , sleep deprivation )
• Sensory deprivation
• systemic diseases (infections)
• fever
• Metabolic disorders : hypoglycemia , hyperglycemia , kidney failure , liver failure , anemia , acidosis , alkalosis , vitamin deficiency , endocrinopathies (adrenal cortex, pituitary, thyroid)
• Electrolyte disorders : Na, K, Ca, Mg, HCO ₃ , PO ₄ , dehydration
• Fracture, trauma
• Malnutrition
• Post anesthesia, postoperatively (e.g. after anesthesia )
• Drugs and delirium (drug-induced side effects, drug intoxication, drug withdrawal)
• Drugs (especially withdrawal for drug or alcohol addicts)
• Cardiovascular: heart failure , myocardial infarction , cardiac arrhythmias , shock , pulmonary embolism
• Hypoxia , hypercapnia
• Obstructive sleep apnea
• Collagen vasculitis (e.g. lupus erythematosus )

The most common cause of delirium in alcoholism is alcohol withdrawal. One then speaks of an alcohol withdrawal delirium : delirium tremens .

Delirium is the most common acute brain dysfunction during intensive care. 50-75% of patients who are ventilated in an intensive care unit develop delirium. Patients who develop delirium in an ICU have a higher risk of death, longer ventilation, and a higher risk of long-term cognitive deterioration than ICU patients without delirium.

Complications

The clouding of consciousness is an important complication and can range from somnolence to sopor and coma . The course of the impaired consciousness can hardly be predicted in delirium. Thus, every delirious syndrome is a psychiatric emergency that can only be treated in a clinic, since in the worst case there is a risk of heart failure, respiratory failure or metabolic disorders .

According to the results of a meta-study from 2015, delirium can be determined in about a third, in a review article from 2019 in 30-80% of patients in intensive care units , in surgical patients between 5.1% and 52.2%, depending on the procedure . Compared to other ICU patients, these patients have a higher mortality rate during their stay there, require a longer stay on average and have more cognitive impairments after discharge.

treatment

Delirium can become a life-threatening, acute medical emergency. Delirium is common in elderly demented patients. Here are dehydration , infections ( pneumonia , urinary tract infections ) and electrolyte derailments common causes. Eliminating the cause (antibiotic therapy, fluid substitution, etc.) and symptomatic treatment with central antisympathetic agents such as clonidine or dexmedetomidine , as well as neuroleptics and benzodiazepines can bring improvement.

Since delirium can occur in the context of a wide variety of disorders, further diagnostics and causal therapy are essential. Treatment must be started immediately after the diagnosis of a delirious syndrome , even without knowing the exact etiology of the delirium.

Overstimulation of the sympathetic nervous system can be treated symptomatically with clonidine or dexmedetomidine . Arousal states can be treated symptomatically with benzodiazepines and hallucinations with neuroleptics ( e.g. haloperidol ). Benzodiazepines should be used with caution, however. Some of them have long-acting metabolites that can contribute to prolonged states of confusion, especially in older patients.

With delirium tremens , also alcohol delirium (Latin delirium alcoholicum ), is used in clinics to treat most of the above. Symptoms also used clomethiazole . This requires close monitoring of the patient's vital functions , as it has a respiratory depressive effect. An alcohol withdrawal delirium can be life-threatening and therefore subject to monitoring. The longer and the more alcohol the patient has consumed, the greater the likelihood of delirium.

Non-pharmacological measures

Occupational therapy and physiotherapy reduce the duration of delirium and should therefore be encouraged. The reduction of delirium is supported by soothing music, avoidance of caffeine and the use of ear plugs and blindfolds.

See also

• Somatopsychology

literature

• Erich Grond : The care of confused old people. Mentally old people and their helpers in human interaction. 9th edition. Lambertus Verlag, Freiburg 2003, ISBN 3-7841-1499-7 . Review by Christine Riesner on socialnet.de .
• John Young, Sharon K Inouye: Delirium in older people ( Memento from October 19, 2007 in the Internet Archive ) (Summary, PDF; 96 kB), British Medical Journal, April 21, 2007, Vol 334, 842-6, doi: 10.1136 /bmj.39169.706574.AD (English).
• C. Spies et al .: Guideline “Analgesia, Sedation and Delirium Management in Intensive Care Medicine” of the Association of Scientific Medical Societies (AWMF), 2015.
• Dieter Ebert; Thomas Loew: Systematic Psychiatry. UNI-MED-Verlag, Bremen [u. a.] 2016, ISBN 978-3-8374-1527-8 .
• Lorenzl, S. et al .: Confusional states in old age: Diagnostics and therapy . In: Dtsch Arztebl Int . No. 109 (21) , 2012, p. 391-400 ( review ).

Web links

Wiktionary: Delir  - explanations of meanings, word origins, synonyms, translations

Wiktionary: Delir  - explanations of meanings, word origins, synonyms, translations

• Juebin Huang: delirium (www.msdmanuals.de, issue for medical professionals).
• Wolfgang Hasemann: Delirium - acute confusion . In: care: palliative. 14, 2012, pp. 4-7.
• Federal Ministry for Family, Women, Family and Health: Dementia and Delirium

Individual evidence

1. ^ Friedrich Kluge , Alfred Götze : Etymological dictionary of the German language . 20th edition. Edited by Walther Mitzka . De Gruyter, Berlin / New York 1967; Reprint (“21st unchanged edition”) ibid 1975, ISBN 3-11-005709-3 , p. 126 ( Delirium ).
2. ↑ Acute state of confusion. A syndrome with many faces .
3. ^ Tilman Wetterling: Psychiatric emergencies. In: Jörg Braun, Roland Preuss (Ed.): Clinic Guide Intensive Care Medicine. 9th edition. Elsevier, Munich 2016, ISBN 978-3-437-23763-8 , pp. 357–369, here: pp. 358–360 ( Delir ).
4. ↑ Reinhold Schüttler (Ed.): Psychiatrische Vorlesungen. A study and reading book. W. Zuckschwerdt, Munich a. a. 1987, ISBN 3-88603-233-7 , p. 27.
5. ↑ Acute confusion in old age .
6. ↑ Norbert Zoremba, Mark Coburn: Delir in the hospital . In: Deutsches Ärzteblatt. 116, 2019, pp. 101-106.
7. ↑ Werner Leibbrand , Annemarie Wettley : The madness history of occidental psychopathology. Karl Alber Verlag, Freiburg im Breisgau / Munich 1961, pp. 323–328.
8. ^ WHO: The ICD-10 Classification of Mental and Behavioral Disorder. Diagnostic criteria for research. 1990
9. ^ American Psychiatric Association: Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC 1994
10. ↑ Norbert Zoremba, Mark Coburn: Acute confusional states in hospital . In: Deutsches Aerzteblatt Online . February 15, 2019, doi : 10.3238 / arztebl.2019.0101 .
11. ↑ Finn M Radtke, Martin Franck, Stefan Oppermann, Alawi Lütz, Matthes Seeling, Anja Heymann, Robin Kleinwächter, Felix Kork, Yoanna Skrobik, Claudia D Spies: The Intensive Care Delirium Screening Checklist (ICDSC) - guideline-compliant translation and validation of intensive care delirium –Checklist . In: anesthesiology, intensive care medicine, emergency medicine, pain therapy . tape 44 , no. 2 , 2009, p. 80-86 , doi : 10.1055 / s-0029-1202647 .
12. ↑ Edward R Marcantonio, Long H Ngo, Margaret O'Connor, Richard N Jones, Paul K Crane: 3D-CAM: Derivation and Validation of a 3-Minute Diagnostic Interview for CAM-Defined Delirium: A Cross-sectional Diagnostic Test Study . In: Annals of Internal Medicine . tape 161 , no. 8 , October 21, 2014, p. 554 , doi : 10.7326 / M14-0865 .
13. Jump up ↑ Babar A Khan, Anthony J Perkins, Sujuan Gao, Siu L Hui, Noll L Campbell: The Confusion Assessment Method for the ICU-7 Delirium Severity Scale: A Novel Delirium Severity Instrument for Use in the ICU . In: Critical Care Medicine . tape 45 , no. 5 , 2017, p. 851-857 , doi : 10.1097 / CCM.0000000000002368 ( ovid.com [accessed June 23, 2019]).
14. ↑ Alawi LÜTZ, Anja Heymann, Finn M Radtke, Chokri Chenitir, Ulrike Neuhaus: Different assessment tools for intensive care unit delirium: Which score to use? *: . In: Critical Care Medicine . tape 38 , no. 2 , 2010, p. 409-418 , doi : 10.1097 / CCM.0b013e3181cabb42 ( ovid.com [accessed June 23, 2019]).
15. ↑ Timothy D. Girard, Jennifer L. Thompson, Pratik P. Pandharipande, Nathan E. Brummel, James C. Jackson: Clinical phenotypes of delirium during critical illness and severity of subsequent long-term cognitive impairment: a prospective cohort study . In: The Lancet. Respiratory Medicine . tape 6 , no. 3 , 2018, p. 213-222 , doi : 10.1016 / S2213-2600 (18) 30062-6 , PMID 29508705 .
16. ↑ E Wesley Ely, Ayumi Shintani, Brenda Truman, Theodore Speroff, Sharon M Gordon: Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit . In: JAMA . tape 291 , no. 14 , April 14, 2004, pp. 1753-1762 , doi : 10.1001 / jama.291.14.1753 , PMID 15082703 .
17. ↑ PP Pandharipande, TD Girard, JC Jackson, A Morandi, JL Thompson: Long-term cognitive impairment after critical illness . In: The New England Journal of Medicine . tape 369 , no. 14 , October 3, 2013, p. 1306-1316 , doi : 10.1056 / NEJMoa1301372 , PMID 24088092 , PMC 3922401 (free full text).
18. ↑ JI Salluh et al. a. (2015): Outcome of delirium in critically ill patients: systematic review and meta-analysis , BMJ (Clinical Research Edition), Vol. 350, p. H2538. PMID 26041151
19. ↑ Norbert Zoremba, Mark Coburn: Acute confusional states in hospital. In: Deutsches Aerzteblatt Online. 2019, doi: 10.3238 / arztebl.2019.0101 .
20. ↑ JI Salluh et al. a. (2015): Outcome of delirium in critically ill patients: systematic review and meta-analysis , BMJ (Clinical Research Edition), Vol. 350, p. H2538. PMID 26041151
21. ↑ Cavallazzi, R., Saad, M. & Marik, PE: Delirium in the ICU: an overview . 2012.

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