Delirium

Delirium is the name given to a set of symptoms that include severe confusion and disoriented thinking and often incorporate delusions and hallucinations. Delirium is caused by a physical, chemical, or structural problem in the brain that did not previously exist. Disease, medications, a newly presented physical deficit, or a combination of these can cause delirium. The onset is sudden, and can begin for the patient in the span of hours or even minutes. The malady had not been carefully studied or addressed until the twenty-first century, and is now considered a disorder of serious importance. It is identified as the most common acute syndrome affecting adults in hospital settings, with 80 percent of intensive care patients suffering from this sickness. Delirium is also a primary predictor of death within a year for those patients experiencing it in critical care settings.

Background

The syndrome now known as delirium was first described in the first century BCE by Celcus as, a person seeming "out of track." Delirium is now understood to be an insidious malady that is present wherever there are sick people. The syndrome has typical attributes that develop rapidly. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) describes delirium as a phenomenon that cannot be explained by things already wrong with a person; delirium is the product or result of a new development in an illness process. More and more is known about delirium, as so many patients who are receiving care in hospitals experience it. The DSM-5 includes detailed symptoms and descriptions of how delirium presents itself. The disturbance of conscious mental functions and changes in cognition are often the first indication that delirium is underway. A patient will seem disoriented and have difficulty focusing on a specific subject in order to solve problems. Disorientation, agitation, and overly complex thinking are also prime indicators of delirium onset. Patients also lose their understanding of where they are and what they are doing. These changes in cognition may also include complex hallucinations, disorientation, and digressing or incoherent conversation. Sleep changes, insomnia, and the sleep-wake cycle are also impacted.

Precipitating circumstances include acute infection, polypharmacy (i.e., several medications that negatively impact psychological health), terminal illness, vascular pathology, unresolved and acute pain, and head injury. If patients are elderly, face multiple comorbidities, are dependent on others, and are dehydrated, the chance of delirium is higher. An individual who is already quite ill is at a much-increased risk of experiencing delirium. As processes in the body degrade, the likelihood of delirium increases.

Impact

Though many hospital patients develop this illness during their stay, over 10 percent of patients are actually discharged from the hospital still experiencing delirium. The outcomes for delirium are negative and include death, more health interventions (cost and pain), and increased length of stay in the intensive care unit or other hospital unit.

Palliative treatments provide pain management and symptom control to patients. Oncology is medical care that treats cancers. Often, oncology patients also receive palliative care to address the complex side effects and symptoms they experience as part of their cancer treatment. Cancer patients with advanced cancer, meaning it is diffuse and in many parts of the body, will often receive palliative care. Nearly half of all cancer patients receiving palliative care have delirium upon admission, while 88 percent of dying cancer patients demonstrate the syndrome. As the burden of the cancer illness increases, so does the likelihood of delirium.

The presence and frequency of delirium in the pediatric population has not been well understood or recognized by health care providers. The frequency of children experiencing delirium who are facing serious illness and pre-terminal conditions is 10 percent. Family distress in the context of cancer confirms that family burden and stress is worsened by the incidence of delirium.

For family, witnessing a loved one make persistent loose associations of thought and speech that make no or limited sense is scary and disturbing. Research demonstrates a profound impact on family, as they undergo a loss of connection with their loved one, are confronted with an increased awareness of terminal likelihood, and are unprepared for the syndrome of delirium demonstrated by their loved one. Health care provider communication with family about delirium has been shown to improve family understanding and coping with the experience of seeing a loved one in the grips of the syndrome.

Health care providers and systems should integrate family involvement in the care of patients with delirium more systematically. Delirium remains a topic of emergent research, and programs of intervention and prevention are still needed to manage this difficult set of symptoms. Findings on treatment and prevention of delirium are fairly new. Since sleep changes are common, minimizing overnight interruptions and disturbance of the patient is important. Reorienting the patient to current surroundings has also been found to support efforts to diagnose delirium early, as well as to intervene once it has begun. Since the cause of delirium is found in etiology, or medications, it is most important to understand and address the originating source of the delirium. Since family is often the first-line witness to the onset of delirium, preparing them for early symptoms and arming family with interventions for the patient, such as reorientation and sleeping support is essential. Supporting family involves recognizing the distress incurred by witnessing delirium, but also providing coping mechanisms for family such as prevention and intervention tools they themselves can employ.

Bibliography

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Otani, H, et al. "Effect of Leaflet-Based Intervention on Family Members of Terminally Il Patients with Cancer Having Delirium: Historical Control Study." American Journal of Hospice and Palliative Medicine 31.3 (2014): 322–26. Print.