So, what is delirium?

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When you search ‘delirium’ on Google images you find lots of pictures to do with delirium tremens – the clinical syndrome associated with alcohol withdrawal; while this is delirium in one sense, it is not the one I am discussing –

The usual textbook definition for delirium is a fluctuating state of consciousness developing over hours or days associated with an external factor and often reversible. (Or words to that effect – this is my definition, rather than the OED’s)

When I was a medical student I never really understood delirium – sure, I saw patients in this ‘state’, but when you are a doctor, particularly one working in a hospital, at least in the early years, you do not have enough experience of people, or of illness to understand something as complex as this (in the 1990’s antipsychotics were often seen as the panacea).

The alteration of consciousness that accompanies delirium can be mild – for example, subtle disruptions to an individual’s proprioceptive sense (causing them to fall) or it can be the whole Aldous Huxley, Doors of Perception, mind-altering, cacophony of symptoms that affects every sensory modality – auditory and visual hallucinations, hyperactivity, pain, anxiety, paranoia –

The causes of delirium are many – the likelihood of a person becoming delirious is often dependent on their constitutional resilience (very often age, frailty and number of associated health conditions being the key factors) and the nature of the insult.

People who have dementia tend to be at the highest risk of experiencing delirium – delirium and dementia being different conditions which predominantly affect older people, the major difference being, that, delirium is potentially curable, reversible and treatable, the latter a progressive, terminal condition. Delirium can however affect anyone.

The many causes of delirium – infections, pain, dehydration, drugs (prescribed, over-the-counter and illicit), constipation, abnormalities of metabolism – low and high blood sugar, low sodium, high calcium, cancer, lack of sleep, change of environment, the list goes on;

All of this points to one thing, that when caring for a person with delirium, a level of inquiry is required that goes beyond the model of ‘confused older person > urine infection > antibiotics’

To address delirium, support the person and aid recovery, we have to examine the them as a whole; holistic practice is one of the greatest things to happen to mainstream medicine in the past five years – no longer are you looked at askance for suggesting this as the way ahead.

How do we treat delirium? We don’t have many cures or treatments for delirium itself, beyond correcting the underlying cause; like Chauncey Gardener in Kozinski’s ‘Being There’, the role of the doctors, the nurses, the carers is to tend, support the patients, prevent them from coming to harm – ensure they receive adequate hydration (cups of tea) and nutrition (person-centred, tasty & what they enjoy), ideally in company (not in bed/at bedside) without exposing them to the harms sometimes encountered in hospital – falls, pressure ulcers and hospital acquired infections being the main ones although loss of independence, institutionalization and loss of self are others.

There is much more to say about delirium, but that is all for now.

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