The delirium debate…

What is delirium?

“Delirium is a state of mental confusion that can happen if you become medically unwell.  It is also known as an ‘acute confusional state’.

Medical problems, surgery and medications can all cause delirium. It often starts suddenly and usually lifts when the condition causing it gets better. It can be frightening – not only for the person who is unwell, but also for those around him or her.” (Royal College of Psychiatrists)

My Consultant’s mantra has always been “If it looks like delirium and sounds like delirium, it probably is delirium”. However, delirium comes in many disguises, and can be tricky to manage. Two current cases of mine spring to mind. Both diagnised with delirium. Both presenting very differently:

Case 1 – 76yr old chap, admitted to hospital 5weeks ago. Two weeks prior to admission, was “his normal self”, still driving, no concerns except he was a little forgetful. He had a funy moment at a family wedding, where he became overheated in the sun and became irritable with his wife, but nothing significant. On the morning of admission, he again became quite feverish. Since admission, he has been acutely confused, hallucinating, fluctuating consciousness, changing mobility, aggressive outbursts. He has had every investigation the medics could think of, including a full MRI under general anaesthetic to rule out malignancy, full blood screening and lumbar puncture. CT brain scan showed some slight changes. Diagnosis – delirium, which may have triggered a dementia which had been slowly emerging prior to this episode. Sadly, he likely to now need full-time 24hour care. His family are understandably devestated, as this was very much an overnight change.

Case 2 – 67yr old lady, admitted with shortness of breath and low sodium (a salt in the blood, which when low will cause confusion and dizziness). Three weeks prior, she had sought G.P. advice about an earache. Antibiotics caused her to vomit. She was also started on an antidepressant, which caused her sodium to drop. She felt unwell, so stopped taking it. Her family became concerned about her increasing confusion levels. There was no previous confusion or memory difficulty. On admission, she was found to be dehydrated and to have a urine infection, on top of the low sodium. She was also diagnised with COPD. Diagnosis – delirium secondary to dehydration, low sodium and UTI. The outcome for this lady is likely to be more positive – antibiotics will treat the infection, she has been rehydrated and she is no longer on medication which effects her sodium levels. Given time, her brain will return to normal functioning.

Same diagnosis, very different outcomes.

About 20% of hospital patients will have a delirium, but if you are an older adult and/or have a dementia, it is more likely that you will experience it. We are often referred patients for assessment of a “sudden onset dementia” when a delirium has not been picked up. We are also referred patients with apparent depression who have a delirium. In all cases, any cause of delirium, e.g. infection, low sodium, alcohol withdrawal, needs to be treated. Delirium can also occur following a trauma/operation due to the inflammation in the body and brain.

Delirium can take weeks to recover from, sometimes months.

Supporting carers through a sudden change in their loved ones can be tough. It is very distressing to see their spouse/parent experiencing such a change in their personality or being terrified by hallucinations. One of the keys to diagnosing delirium is talking to the families. What was the person like before this change? If there was no confusion or memory difficulty, delirium is the most likely diagnosis.

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