Literature Review on Delirium Disorder

Special Topics

Delirium

Introduction

The purpose of this paper is to expand the knowledge to the audience of the neurocognitive disorder, otherwise known as NCDs. The specific topic that I am fulfilling is known as delirium. According to (American Psychiatric Association. (2013):

“The prevalence of delirium is highest among hospitalized older individuals and varies depending on the individuals’ characteristics, setting of care, and sensitivity of the detection method. The prevalence of delirium in the community overall is low (1%–2%) (Inouye 2006) but increases with age, rising to 14% among individuals older than 85 years. The prevalence is 10%–30% in older individuals presenting to emergency departments, where the delirium often indicates a medical illness (Inouye 2006).The prevalence of delirium when individuals are admitted to the hospital ranges from 14% to 24%, and estimates of the incidence of delirium arising during hospitalization range from 6% to 56% in general hospital populations (Agostino and Inouye 2003; Inouye 1998). Delirium occurs in 15%–53% of older individuals postoperatively (Agostino and Inouye 2003) and in 70%–87% of those in intensive care (Pisani et al. 2003). Delirium occurs in up to 60% of individuals in nursing homes or post–acute care settings (Boorsma et al. 2012) and in up to 83% of all individuals at the end of life (Casarett 2003)”.

The paper will also consist of the discussion and criteria of what delirium is, what past and present empirical research from literature, and evidence-based treatment plans.

Discussion of Disorder & Criteria

  To begin with, “Delirium is an acute (hours, days), severe deterioration in mental functioning mostly occurring in the context of medical illness, trauma, drugs, or surgery” (MacLullich, 2018). There are multiple forms of delirium that include: (a) substance intoxication delirium (b) substance withdrawal delirium (c) medication-induced delirium (d) delirium to another medical condition (e) delirium due to multiple etiologies (f) other specified delirium such as attenuated delirium syndrome and (g) and unspecified delirium.

In addition, delirium is associated with the sleep-wake cycle which means that the disturbances can cause daytime sleepiness, nighttime agitation, difficulty falling asleep, excessive sleepiness throughout the day, or wakefulness throughout the night (American Psychiatric Association. (2013). The individual may show emotional disturbances behaviors as well such as anxiety, fear, depression, and anger. For example, during this state of delirium, the individual may act among the emotional state by making noises such as screaming or calling out.

Secondly, from personal experience the hallucinations from delirium can be highly scary. I personally experienced delirium after my 18-hour chest surgery.  These hallucinations are extremely realistic and can agitate the individual. For example, I tried to remove my ventilator due to the hallucinations (from delirium) that made me believe the hospital staff was trying to murder me. A large population of individuals that suffer from delirium are in the intensive care unit (ICU) such as I was at the time of my hallucinations. Lough (2019, p. 81) implies that all patients that are critically ill, like the ones in the intensive care unit should all be assessed for possibility of delirium. The assessment scale for these individuals is known as “The Intensive Care Delirium Screening Checklist” (ICDSC) and is point based over an eight-hour shift, or from the previous 24 hours.

 However, if I were to focus on another form of delirium to expand knowledge about, it would be substance withdrawal delirium. Individuals who are suffering from delirium from a substance, such as alcohol cause delirium tremens (DTs). The combination of alcohol withdrawal and delirium can be deadly, and these symptoms consist of hallucinations, seizures,  increased need for mechanical ventilation (Lough, 2019). The individuals that clinicians often see who are suffering from delirium due to substance withdrawal are located in the emergency department (Aldelbrahamn, Borden & Ghamloush, 2018). 

In order to diagnosis an individual with any form of delirium one must have (a) disturbance in attention such as reduced ability to focus (b) the disturbance develops over a short period of time usually in hours to a few days (c) additional disturbances in cogitation such as disorientation and language, (d) criteria in a and b are not explained due to another condition and (e) there is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawals, or explore to a toxin, or is due to multiple etiologies (American Psychiatric Association. (2013).” However, if an individual is suffering from substance withdrawal delirium, the clinician must pay attention to criteria (a) and (c).

Literature

 As mentioned, delirium occurs frequently for individuals that are in the intensive care unit. Case study: “Effect of organizational factors on the variation in incidence of delirium in intensive care unit patients: A systematic review and meta-regression analysis” discusses the delirium occurrence rates.  The objective of this study was to determine if organizational factors could contribute to observed delirium in adult intensive care patients (Rood, Vermeulen, Schoohoven, Pickkers, & Van den Boogaard, 2018).  The large case study resulted in 4% to 89% have individual delirium occurrence rates. Researchers wanted a more precise percentage to report, therefore, the researchers performed a meta-regression analysis based off the available organizational factors which includes hospital type, screening method and screening frequency. A total of 9867 intensive care patients were included in this study, the results concluded that 29% of these individuals had delirium in the intensive care unit.

 Another case study, “Severe alcohol withdrawal syndrome: review of the literature” discussed additional risk factors an individual can have while withdrawing from a substance, in this case, alcohol. This study was conducted over 16 years from 1989 to 2017 in which clinicians looked at individuals with ADS, delirium tremens (DTs), alcohol-related seizures or alcohol withdrawal syndrome. This specific case was beneficial for me because of the delirium tremens. The study reported that out of the 205 studies screens only six of the individuals met the criteria for delirium tremens (Benson, Roberts, McCallum & McPherson, 2019). One last case study, “Alcohol withdrawal delirium- diagnosis, course, and treatment” explains the most severe side effect from individuals withdrawing (Mainerova et al. ,2015). The study that was conducted stated that delirium occurs within 24 to 72 hours if that is a side effect an individual will develop while withdrawing/ detoxing. The study was done through inpatient trails but had a very small sample size.  At the end of the study, it was concluded that individuals appear after longer than “normal” heavy binge drinking. Delirium tremens associated with alcohol resulted in the protentional of death aforementioned but can cause severe morbidity as well if the tremens were not managed properly.

Treatment

 According to (Mainerova et al., 2015) study, the most effective treatment for individuals with delirium from alcohol is best managed in the intensive care unit and given short acting benzodiazepines in supramaximal doses. Throughout the study, other drugs were tested, but found not effective, or not as effective. For example, barbiturates were reported in cases of alcohol withdrawal delirium did not respond to the delirium (Caplan, n.d). The case study also reported that having proper subsequent care after the delirium subsides is important. This was an important factor because the individual needs proper education and psychological support to understand the delirium that had occurred.

 Another evidence-based intervention to apply to individuals with delirium is a non-pharmacological approach. This intervention consists of prevention of delirium. The first step is to identify high risk factors which include: (a) non-treatable delirium risk factors, (b) old age, (c) underlying dementia, (d) male gender, (e) previous history of delirium, (f) significant medical history, (g) poor eye sight and hearing, (h) frailty, and (i) immobility (Tabet & Howard, 2009). Next, would be how the clinicians can help prevent those with targeted risk factors, and lastly, for the clinician to recognize possible start of delirium and help the individual identify with reality as best as possible.

Conclusion

 In conclusion, there are multiple forms of delirium. Through research delirium appears most common in elderly patients, substance withdrawal (alcohol or drugs), and surgery patients. The challenge I believe that is most difficult with delirium is when individuals may not show risk factors at all and suddenly have delirium. Or, clinicians can attempt educational based interventions, but the mind is strong. As I mentioned, I had delirium after my surgery and the answer was never diagnosed if my delirium was from being under anesthesia so long, the mixture of pain killers, or both. The DSM-5 explains delirium very well, however, I do believe if other interventions were listed this could be beneficial. At my internship, we had a man who was AAOx3 before surgery and, after surgery, did not know any information about himself except his name and age. This individual could not remember who he was for two weeks, and one day, everything came back. In my opinion, delirium has the protentional to be predictable but for individuals who are high risk. As for treatment, I think preventative measures and reassuring individuals of who they are can be helpful, but there is no “magic” answer to have an individual remember who they are.

References:

• Abdelrahman, A., Borden, M., & Ghamloush, M. A. (2018). Agitated Delirium in an Intravenous Drug User: Don’t Jump to Conclusions. In D46. CRITICAL CARE CASE REPORTS: TOXICOLOGY AND POISONINGS (pp. A6929-A6929). American Thoracic Society.
• Agostini JV, Inouye SK: Delirium, in Principles of Geriatric Medicine and Gerontology, 5th Edition. Edited by Hazzard WR, Blass JP, Halter JB, et al. New York, McGraw-Hill, 2003, pp 1503–1515
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
• Benson, G., Roberts, N., McCallum, J., & McPherson, A. (2019). Severe alcohol withdrawal syndrome: review of the literature. Drugs and Alcohol Today.
• Boorsma M, Joling KJ, Frijters DH, et al: The prevalence, incidence and risk factors for delirium in Dutch nursing homes and residential care homes. Int J Geriatr Psychiatry 27(7):709–715, 2012 10.1002/gps.2770 21919058
• Casarett DJ: Assessing decision-making capacity in the setting of palliative care research. J Pain Symptom Manage 25(4):S6–S13, 2003 12691692
• Caplan JP. Diagnosis and treatment of agitation and delirium in the intensive care unit patient. In: Irwin RS &, Rippe JM, editors. Intensive care medicine, 6th ed. Philadelphia: Lippincott Williams & Wilkins 2008;2287-95.
• Inouye SK: Delirium in hospitalized older patients. Clin Geriatr Med 14(4):745–764, 1998 9799477
• Inouye SK: Delirium in older persons. N Engl J Med 354(11):1157–1165, 2006 16540616
• Lough, M. E. (2019). Sedation and Delirium Management. Priorities in Critical Care Nursing, 289, 72.
• MacLullich, A. M. (2018). Delirium. In Learning Geriatric Medicine (pp. 81-87). Springer, Cham.
• Mainerova, B., Prasko, J., Latalova, K., Axmann, K., Cerna, M., Horacek, R., & Bradacova, R. (2015). Alcohol withdrawal delirium-diagnosis, course and treatment. Biomedical Papers of the Medical Faculty of Palacky University in Olomouc, 159(1).
• Pisani MA, McNicoll L, Inouye SK: Cognitive impairment in the intensive care unit. Clin Chest Med 24(4):727–737, 2003 14710700