Delirium

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Delirium (acute confusional state) is a common and severe neuropsychiatric syndrome with core features of acute onset and fluctuating course, attentional deficits and generalized severe disorganization of behavior. It typically involves other cognitive deficits, changes in arousal (hyperactive, hypoactive, or mixed), perceptual deficits, altered sleep-wake cycle, and psychotic features such as hallucinations and delusions. It is often caused by a disease process 'outside' the brain, such as common forms of infection (UTI, pneumonia) or by drug effects, particularly anticholinergic or other CNS depressants (benzodiazapenes and opioids). It can also be caused by virtually any primary disease of the central nervous system. Though hallucinations and delusions are sometimes present, these are not required for the diagnosis, and the symptoms of delirium are clinically distinct from those induced by psychosis or hallucinogens (with the exception of deliriants.) Although commonly referred to as a primary disorder of attention, other core cognitive processes are disrupted, particularly working memory and virtually all aspects of executive functions (planning and organization of behavior). Although it is commonly regarded as reversible, induction of delirium in patients with dementia due to Alzheimer's disease appears to accelerate cognitive decline, suggesting that efforts to prevent and minimize the induction of confusional states in the elderly should be given high priority. Unfortunately, many instances of confusional state (delirium) are iatrogenic (caused by medicines or hospital-borne pathogens/bacteria or surgeries and anesthesia).

In medical usage it is not synonymous with drowsiness, and may occur without it. Delirium is not the same as dementia (the two entities have different diagnostic criteria), though it commonly occurs in demented patients.

Delirium may be of a hyperactive variety manifested by 'positive' symptoms of agitation or combativeness, or it may be of a hypoactive variety (often referred to as 'quiet' delirium) manifested by 'negative' symptoms such as inability to converse or focus attention or follow commands. While the common non-medical view of a delirious patient is one who is hallucinating, most people who are medically delirious do not have either hallucinations or delusions. Delirium is commonly associated with a disturbance of consciousness (e.g., reduced clarity of awareness of the environment). The change in cognition (memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance, must be one that is not better accounted for by a pre-existing, established, or evolving dementia. Usually the rapidly fluctuating time course of delirium is used to help in the latter distinction.[1]

Delirium itself is not a disease, but rather a clinical syndrome (a set of symptoms), which result from an underlying disease or new problem with mentation. Like its components (inability to focus attention, mental confusion and various impairments in awareness and temporal and spatial orientation), delirium is simply the common symptomatic manifestation of early brain or mental dysfunction (for any reason).

Without careful assessment, delirium can easily be confused with a number of psychiatric disorders because many of the signs and symptoms are conditions present in dementia, depression, and psychosis.[2] Delirium is probably the single most common acute disorder affecting adults in general hospitals. It affects 10-20% of all hospitalized adults, and 30-40% of elderly hospitalized patients and up to 80% of ICU patients.

Treatment of delirium requires treatment of the underlying causes. In some cases, temporary or palliative or symptomatic treatments are used to comfort patients or to allow better patient management (for example, a patient who, without understanding, is trying to pull out a ventilation tube that is required for survival).

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