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Delirium
Classification and external resources
ICD-10 F05.
ICD-9 293.0
DiseasesDB 29284
eMedicine med/3006
MeSH D003693

Delirium is a common and severe neuropsychiatric syndrome with core features of acute onset and fluctuating course and attentional deficits. It also often involves other cognitive deficits, changes in arousal (hyperactive, hypoactive, or mixed), perceptual deficits, altered sleep-wake cycle, and psychotic features including hallucinations and delusions. It is often cause by a disease process out with the brain, such as pneumonia or by drug effects. It can also be caused by primary disease of the central nervous system. Though hallucinations and delusions are often present, the symptoms of delirium are clinically distinct from those induced by psychosis or hallucinogens.

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.[3]

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).

Educational information is available for medical and non-medical persons with videos, management protocols, links to references, lectures, recent evidence from studies, implementation packets for hospitals, and even comments to families and loved ones for those witnessing someone going through a delirious episode. [4] See the Resources section. Another usual source of information is the website of the European Delirium Association www.europeandeliriumassociation.com.

Contents

Common versus medical usage

In common usage, delirium is often used to refer to drowsiness, disorientation, and hallucination. In broader medical terminology, however, a number of other symptoms, including a sudden inability to focus attention, and even (occasionally) sleeplessness and severe agitation and irritability, also define "delirium," and hallucination, drowsiness, and disorientation are not required. Known before as 'acute confusional state', delirium is one of the oldest forms of mental disorder known in medical history.[5]

There are several medical definitions of delirium (including those in the DSM-IV and ICD-10). However, all include some core features.

The core features are:

  • Disturbance of consciousness (that is, reduced clarity of awareness of the environment, with reduced ability to focus, sustain, or shift attention)
  • Change in cognition (e.g., problem-solving impairment or memory impairment) or a perceptual disturbance
  • Onset of hours to days, and tendency to fluctuate.

Common features also tend to include:

  • Intrusive abnormalities of awareness and affect, such as hallucinations or inappropriate emotional states.

Diagnosis

Differential points from other processes and syndromes that cause cognitive dysfunction:

  • Delirium may be distinguished from psychosis, in which consciousness and cognition may not be impaired (however, there may be overlap, as some acute psychosis, especially with mania, is capable of producing delirium-like states).
  • Delirium is distinguished from dementia (chronic organic brain syndrome) which describes an "acquired" (non-congenital) and usually irreversible cognitive and psychosocial decline in function. Dementia usually results from an identifiable degenerative brain disease (for example Alzheimer disease or Huntington's disease). Dementia is usually not associated with a change in level of consciousness, and a diagnosis of dementia requires a chronic impairment.
  • Delirium is distinguished from depression.
  • Delirium is distinguished by time-course from the confusion and lack of attention which result from long term learning disorders and varieties of congenital brain dysfunction. Delirium has also been referred to as 'acute confusional state' or 'acute brain syndrome'. The key word in both of these descriptions is "acute" (meaning: of recent onset), since delirium may share many of the clinical (i.e., symptomatic) features of dementia, developmental disability, or attention-deficit hyperactivity disorder, with the important exception of symptom duration.
  • Delirium is not the same as confusion, although the two syndromes may overlap and be present at the same time. However, a confused patient may not be delirious (an example would be a stable, demented person who is disoriented to time and place), and a delirious person may not be confused (for example. a person in severe pain may not be able to focus attention, but may be completely oriented and not at all confused).

It is a corollary of the above differential criteria that a diagnosis of delirium cannot be made without a previous assessment or knowledge of the affected person's baseline level of cognitive function.

Several valid and reliable rating scales now exist which can be used to accurately diagnose delirium by trained individuals.[6][7] www.icudelirium.org

Occurrence in hospitals

The highest prevalence of delirium (often 50% to 75% of patients) is generally seen in critically ill patients in the intensive care unit or ICU (which used to be referred to by the misnomer ICU Psychosis, a term largely abandoned now for the more widely accepted and scientifically supported term delirium). Since the advent of validated and easy to implement delirium instruments for ICU patients such as the Confusion Assessment Method for the ICU (CAM-ICU)[6] and the Intensive Care Delirium Screening Checkllist (IC-DSC)[8]. Of the hundreds of thousands of ICU patients develop delirium in ICUs every year, it has been recognized that most of them being of the hypoactive variety that is easily missed and invisible to the managing teams unless actively monitored using such instruments. The causes of delirium in such patients depend on the underlying illnesses, new problems like sepsis and low oxygen levels, and the sedative and pain medicines that are nearly universally given to all ICU patients. Outside the ICU, on hospital wards and in nursing homes, the problem of delirium is also a very important medical problem, especially for older patients. The most recent area of the hospital in which delirium is just beginning to be monitored routinely in many centers is the Emergency Department. Also, one in four geriatric patients suffer from an episode of delirium at least once during their stay in the hospital.

Commonly co-occurring mental symptoms, with a note on severity

Since delirium may occur in very many grades of severity, all symptoms may occur with varying degrees of intensity. A mild disability to focus attention may result in only a disability in solving the most complex problems. As an extreme example, a mathematician with the flu may be unable to perform creative work, but otherwise may have no difficulty with basic activities of daily living. However, as delirium becomes more severe, it disrupts other mental functions, and may be so severe that it borders on unconsciousness or a vegetative state. In the latter state, a person may be awake and immediately aware and responsive to many stimuli, and capable of coordinated movements, but unable to perform any meaningful mental processing task at all.

Inability to focus attention, confusion and disorientation

The delirium-sufferer loses the capacity for clear and coherent thought. This may be apparent in disorganised or incoherent speech, the inability to concentrate (focus attention), or in a lack of any goal-directed thinking. These limitations in thought may also be manifested as purposeless behavior, such as rummaging or punding, or as a difficulty completing a single purpose-oriented task - to the extent that a delirious individual may engage in a string of incomplete and unrelated activities.

Disorientation (another symptom of confusion, and usually a more severe one) describes the loss of awareness of the surroundings, environment and context in which the person exists. It may also appear with delirium, but it is not required, as noted. Disorientation may occur in time (not knowing what time of day, day of week, month, season or year it is), place (not knowing where one is) or person (not knowing who one is).

Cognitive function may be impaired enough to make medical criteria for delirium, even if orientation is preserved. Thus, a patient who is fully aware of where they are and who they are, but cannot think because they cannot concentrate, may be medically delirious. The state of delirium most familiar to the average person is that which occurs from extremes in pain, lack of sleep, or emotional shock.

Because most high level mental skills are required for problem solving, including ability to focus attention, this ability also suffers in delirium. However, this is a secondary phenomenon, since problem-solving involves many sub-skills and basic mental abilities, any of which may be impaired in a delirious patient.

Memory formation disturbance

Impairments to cognition may include temporary reduction in the ability to form short-term or long-term memory. Difficult short-term memory tasks like ability to repeat a phone number may be continuously disrupted during a delirium, but easier short-term memory tasks like repeating single words, or remembering simple questions long enough to give an answer, may not be impaired. Reduction in formation of new long-term memory (which by definition survive withdrawal of attention), is common in delirium, because initial formation of (new) long-term memories generally requires an even higher degree of attention, than do short-term memory tasks. Since older memories are retained without need of concentration, previously formed long-term memories (i.e., those formed before the period of delirium) are usually preserved in all but the most severe cases of delirium (and when destroyed, are destroyed by the underlying brain pathology, not the delirious state per se).

Abnormalities of awareness and affect

Hallucinations (perceived sensory experience with the lack of an external source) or distortions of reality may occur in delirium, but they are not essential for the diagnosis. Commonly these are visual distortions, and can take the form of masses of small crawling creatures (particularly common in delirium tremens, caused by severe alcohol withdrawal) or distortions in size or intensity of the surrounding environment.

Strange beliefs may also be held during a delirious state, but these are not considered fixed delusions in the clinical sense as they are considered too short-lived (i.e., they are temporary delusions - such as thinking that a nurse is a person from his/her past trying to cause injury). Interestingly, in some cases sufferers may be left with false or delusional memories after delirium, basing their memories on the confused thinking or sensory distortion which occurred during the episode of delirium. Other instances would be inability to distinguish reality from dreams.

Abnormalities of affect which may attend the state of delirium may include many distortions to perceived or communicated emotional states. Emotional states may also fluctuate, so that a delirious person may rapidly change between, for example, terror, sadness and jocularity.

Duration

The duration of delirium is typically affected by the underlying cause. If caused by a fever, the delirious state often subsides as the severity of the fever subsides. However, it has long been suspected that in some cases delirium persists for months and that it may even be associated with permanent decrements in cognitive function. Barrough said in 1583 that if delirium resolves, it may be followed by a "loss of memory and reasoning power." Recent studies bear this out, with cognitively normal patients who suffer an episode of delirium carrying an increased risk of dementia in the years that follow. In many such cases, however, delirium undoubtedly does not have a causal nature, but merely functions as a temporary unmasking with stress, of a previously unsuspected (but well-compensated) state of minimal brain dysfunction (early dementia).

Causes

Delirium is a very general and nonspecific symptom of organ dysfunction, where the organ in question is the brain. In addition to many organic causes relating to a structural defect or a metabolic problem in the brain, there are also some psychiatric causes, which may include a component of mental or emotional stress, or mental disease.

Delirium may be caused by physical illness, which can be mild, or any process which interferes with the normal metabolism or function of the brain.[9] For example, fever, pain, poisons (including toxic drug reactions), brain injury, surgery, traumatic shock, lack of food or water or sleep, and even withdrawal symptoms of certain drug and alcohol dependent states, are all known to cause delirium.

In addition, there is an interaction between acute and chronic symptoms of brain dysfunction; delirious states are more easily produced in people already suffering with underlying chronic brain dysfunction.[10]

A very common cause of delirium in elderly people is a urinary tract infection, which is easily treatable with antibiotics, reversing the delirium.

Too many to list by specific pathology, major categories of the cause of delirium include:

Critical illness

The most common behavioral manifestation of acute brain dysfunction is delirium, which occurs in up to 60% to 80% of mechanically ventilated medical and surgical ICU patients and 50% to 70% of non-ventilated medical ICU patients.[11] During the ICU stay, acute delirium is associated with complications of mechanical ventilation including nosocomial pneumonia, self-extubation, and reintubation.[3] ICU delirium predicts a 3- to 11-fold increased risk of death at 6 months even after controlling for relevant covariates such as severity of illness.[3] Of late, delirium has been recognized by some as a sixth vital sign, and it is recommended that delirium assessment be a part of routine ICU management.[12] The elderly may be at particular risk for this spectrum of delirium and dementia.[12] A firm understanding of the pathophysiologic mechanisms of delirium remains elusive despite improved diagnosis and potential treatments. www.icudelirium.org

Substance withdrawal

Drug withdrawal is a common cause of delirium. The most notable are alcohol withdrawal and benzodiazepine withdrawal but other drug withdrawals both from licit and illicit drugs can sometimes cause delirium.

Gross structural brain disorders

  • Head trauma (i.e., concussion, traumatic bleeding, penetrating injury, etc.)
  • Gross structural damage from brain disease (stroke, spontaneous bleeding, tumor, etc.)

Neurological disorders

Circulatory

Lack of essential metabolic fuels, nutrients, etc.

Toxication

Mental illness per se is not a cause, as a matter of definition

Some mental illnesses, such as mania, or some types of acute psychosis, may cause a rapidly fluctuating impairment of cognitive function and ability to focus. However, they are not technically causes of delirium, since any fluctuating cognitive symptoms that occur as a result of these mental disorders are considered by definition to be due to the mental disorder itself, and to be a part of it. Thus, physical disorders can be said to produce delirium as a mental side-effect or symptom; however primary mental disorders which produce the symptom cannot be put into this category, once identified. However, such symptoms may be impossible to distinguish clinically from delirium resulting from physical disorders, if a diagnosis of an underlying mental disorder has yet to be made.

Treatment

Delirium is not a disease, but a syndrome (i.e. collection of symptoms) indicating dysfunction of the brain, in the same way shortness of breath describes dysfunction of the respiratory system, but does not identify the disorder. Treatment of delirium involves two main strategies. First, treatment of the underlying presumed acute cause or causes. Second, optimising conditions for the brain. This involves ensuring that the patient with delirium has adequate oxygenation, hydration, nutrition, and normal levels of metabolites, that drug effects are minimised, constipation treated, pain treated, and so on. Detection and management of mental stress is also very important. Thus, the traditional concept that the treatment of delirium is 'treat the cause' is not adequate; patients with delirium actually require a highly detailed and expert analysis of all the factors which might be disrupting brain function.

The first line choice of pharmacological treatment for delirium depends on its cause. Antipsychotics are the most commonly used drugs for delirium and the most studied. Benzodiazepines themselves can cause delirium or worsen it and are generally ineffective for most causes of delirium; however, if delirium is due to sedative-hypnotic withdrawal, e.g. alcohol withdrawal or benzodiazepine withdrawal or the patient cannot take antipsychotics (eg. in Parkinson's disease then benzodiazepines are recommended and the most effective treatment. Palliative or symptomatic treatment of delirium is sometimes necessary to make a patient comfortable. Antipsychotics, preferably those with minimal anticholinergic activity, such as haloperidol or risperidone may be preferred.[13][14][15]

Other evidence also suggests that non-pharmacological measures may also be effective in decreasing the incidence of delirium.[16] Because delirium is a mere symptom of another problem which may be very subtle, the wisdom of treatment of the delirious patient with drugs must overcome natural skepticism, and requires a high degree of skill.

There have been reports that cholinesterase inhibitors might be effective in treating delirium, but there is little evidence for this.[17]

Accounts of delirium

Sims (1995, p. 31) points out a "superb detailed and lengthy description" of delirium in The Stroller's Tale from Charles Dickens' The Pickwick Papers.[18][19]

Resources

Further information and resources, including the Stop Delirium project and delirium guidelines from other countries are also available on the new European Delirium Association website www.europeandeliriumassociation.com.

The Association are holding their 2 day Annual Scientific Meeting in Amsterdam, The Netherlands on November 11th and 12th 2010. There is a powerful presentation including delirium on the Let's Respect campaign pages, part of the work of the National mental health in later life Programme's website which includes further statistics relating to delirium in older adults in hospitals in England. www.mentalhealthequalties.org.uk/letsrespectThis resource also includes podcasts involving Professor Alasdair MacLullich speaking about Delirium and Dr Valerie Page speaking on Delirium in ICU

The site also has links to a number of sites containing information and resources on the condition Delirium resources

See also

References

  1. ^ "Delirium - Cleveland Clinic". http://www.clevelandclinicmeded.com/diseasemanagement/psychiatry/delirium/delirium.htm. Retrieved 2007-06-11. 
  2. ^ American Family Physician, March 1, 2003 Delirium
  3. ^ a b c Ely EW, Shintani A, Truman B, et al. (2004). "Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit". JAMA 291 (14): 1753–62.. doi:10.1001/jama.291.14.1753. PMID 15082703. 
  4. ^ "ICU Delirium.org". http://www.icudelirium.org. Retrieved 2008-03-24. (see www.icudelirium.org).
  5. ^ Berrios G E (1981) Delirium and Confusion in the 19th century. British Journal of Psychiatry 139: 439-449
  6. ^ a b E. W. Ely, S. K. Inouye, G. R. Bernard, S. Gordon, J. Francis, L. May, B. Truman, T. Speroff, S. Gautam, R. Margolin, R. P. Hart, and R. Dittus. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 286 (21):2703-2710, 2001.
  7. ^ N. Bergeron, M. J. Dubois, M. Dumont, S. Dial, and Y. Skrobik. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med 27 (5):859-864, 2001.
  8. ^ N. Bergeron, M. J. Dubois, M. Dumont, S. Dial, and Y. Skrobik. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med 27 (5):859-864, 2001.
  9. ^ Loss of IQ in the ICU brain injury without the insult. Med Hypotheses. 2007;69(6):1179-82. Epub 2007 Jun 6. PMID: 17555884
  10. ^ Gunther ML, Jackson JC, Ely EW. The cognitive consequences of critical illness: practical recommendations for screening and assessment. Crit Care Clin. 2007 Jul;23(3):491-506. Review. PMID: 17900482
  11. ^ Gunther ML, Morandi, A, Ely EW, et al. (2008). "Pathophysiology of delirium in the intensive care unit.". Critical Care Clinics 24 (1): 45–65.. doi:10.1016/j.ccc.2007.10.002. PMID 18241778. 
  12. ^ a b Flaherty JH, Rudolph J, Shay K, et al. (2007). "Delirium is a serious and under-recognized problem: why assessment of mental status should be the sixth vital sign". J Am Med Dir Assoc 8 (5): 273–5.. doi:10.1016/j.jamda.2007.03.006. PMID 17234820. 
  13. ^ Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, Shintani AK, Thompson JL, Jackson JC, Deppen SA, Stiles RA, Dittus RS, Bernard GR, Ely EW. n. JAMA. 2007 Dec 12;298(22):2644-53. PMID: 18073360
  14. ^ Lonergan E, Luxenberg J, Areosa Sastre A, Wyller TB (2009). "Benzodiazepines for delirium". Cochrane Database Syst Rev (1): CD006379. doi:10.1002/14651858.CD006379.pub2. PMID 19160280. http://dx.doi.org/10.1002/14651858.CD006379.pub2. 
  15. ^ Tyrer, Peter; Silk, Kenneth R., eds (24 January 2008). "Delerium". Cambridge Textbook of Effective Treatments in Psychiatry (1st ed.). Cambridge University Press. pp. 175–184. ISBN 978-0521842280. http://books.google.co.uk/books?id=HLPXELjTgdEC&pg=PA175. 
  16. ^ Inouye SK, Bogardus ST, Charpentier PA, et al. (March 1999). "A multicomponent intervention to prevent delirium in hospitalized older patients". N. Engl. J. Med. 340 (9): 669–76. PMID 10053175. http://content.nejm.org/cgi/pmidlookup?view=short&pmid=10053175&promo=ONFLNS19. 
  17. ^ Overshott R, Karim S, Burns A (2008). "Cholinesterase inhibitors for delirium". Cochrane Database Syst Rev (1): CD005317. doi:10.1002/14651858.CD005317.pub2. PMID 18254077. http://dx.doi.org/10.1002/14651858.CD005317.pub2. 
  18. ^ Sims, Andrew (2002). Symptoms in the mind: an introduction to descriptive psychopathology. Philadelphia: W. B. Saunders. ISBN 0-7020-2627-1. 
  19. ^ Dickens, C. (1837) The Pickwick Papers. Available for free on Project Gutenberg.

Further reading

  • Burns A, Gallagley A, Byrne J (2004). "Delirium". J. Neurol. Neurosurg. Psychiatr. 75 (3): 362–7. doi:10.1136/jnnp.2003.023366. PMID 14966146. 
  • Macdonald, Alastair; Lindesay, James; Rockwood, Kenneth (2002). Delirium in old age. Oxford [Oxfordshire]: Oxford University Press. ISBN 0-19-263275-2. 

Delirium is used in on the track (Stop) playing with my Delirium from the Ladyhawke Album 2008


1911 encyclopedia

Up to date as of January 14, 2010

From LoveToKnow 1911

DELIRIUM (a Latin medical term for madness, from delirare, to be mad, literally to wander from the lira, or furrow), a temporary form of brain disorder, generally occurring in connexion with some special form of bodily disease. It may vary in intensity from slight and occasional wandering of the mind and incoherence of expression, to fixed delusions and violent maniacal excitement, and again it may be associated with more or less of coma or insensibility. (See Insanity, and Neuropathology.) Delirium is apt to occur in most diseases of an acute nature, such as fevers or inflammatory affections, in injuries affecting the brain, in blood diseases, in conditions of exhaustion, and as the result of the action of certain specific poisons, such as opium, Indian hemp, belladonna, chloroform and alcohol.

Delirium tremens is one of a train of symptoms of what is termed in medical nomenclature acute alcoholism, or excessive indulgence in alcohol. It must, however, be observed that this disorder, although arising in this manner, rarely comes on as the result of a single debauch in a person unaccustomed to the abuse of stimulants, but generally occurs in cases where the nervous system has been already subjected for a length of time to the poisonous action of alcohol, so that the complaint might be more properly regarded as acute supervening on chronic alcoholism. It is equally to be borne in mind that many habitual drunkards never suffer from delirium tremens.

It was long supposed, and is indeed still believed by some, that delirium tremens only comes on when the supply of alcohol has been suddenly cut off; but this view is now generally rejected, and there is abundant evidence to show that the attack comes on while the patient is still continuing to drink. Even in those cases where several days have elapsed between the cessation from drinking and the seizure, it will be found that in the interval the premonitory symptoms of delirium tremens have shown themselves, one of which is aversion to drink as well as food - the attack being in most instances preceded by marked derangement of the digestive functions. Occasionally the attack is precipitated in persons predisposed to it by the occurrence of some acute disease, such as pneumonia, by accidents, such as burns, also by severe mental strain, and by the deprivation of food, even where the supply of alcohol is less than would have been likely to produce it otherwise. Where, on the other hand, the quantity of alcohol taken has been very large, the attack is sometimes ushered in by fits of an epileptiform character.

One of the earliest indications of the approaching attack of delirium tremens is sleeplessness, any rest the patient may obtain being troubled by unpleasant or terrifying dreams. During the day there is observed a certain restlessness and irritability of manner, with trembling of the hands and a thick or tremulous articulation. The skin is perspiring, the countenance oppressed-looking and flushed, the pulse rapid and feeble, and there is evidence of considerable bodily prostration. These symptoms increase each day and night for a few days, and then the characteristic delirium is superadded. The patient is in a state of mental confusion, talks incessantly and incoherently, has a distressed and agitated or perplexed appearance, and a vague notion that he is pursued by some one seeking to injure him. His delusions are usually of transient character, but he is constantly troubled with visual hallucinations in the form of disagreeable animals or insects which he imagines he sees all about him. He looks suspiciously around him, turns over his pillows, and ransacks his bedclothes for some fancied object he supposes to be concealed there. There is constant restlessness, a common form of delusion being that he is not in his own house, but imprisoned in some apartment from which he is anxious to escape to return home. In these circumstances he is ever wishing to get out of bed and out of doors, and, although in general he may be persuaded to return to bed, he is soon desiring to get up again. The trembling of the muscles from which the name of the disease is derived is a prominent but not invariable symptom. It is most marked in the muscles of the hands and arms and in the tongue. The character of the delirium is seldom wild or noisy, but is much more commonly a combination of busy restlessness and indefinite fear. When spoken to, the patient can answer correctly enough, but immediately thereafter relapses into his former condition of incoherence. Occasionally maniacal symptoms develop themselves, the patient becoming dangerously violent, and the case thus assuming a much graver aspect than one of simple delirium tremens.

In most cases the symptoms undergo abatement in from three to six days, the cessation of the attack being marked by the occurrence of sound sleep, from which the patient awakes in his right mind, although in a state of great physical prostration, and in great measure if not entirely oblivious of his condition during his illness.

Although generally the termination of an attack of delirium tremens is in recovery, it occasionally proves fatal by the supervention of coma and convulsions, or acute mania, or by exhaustion, more especially when any acute bodily disease is associated with the attack. In certain instances delirium tremens is but the beginning of serious and permanent impairment of intellect, as is not infrequently observed in confirmed drunkards who have suffered from frequent attacks of this disease. The theory once widely accepted, that delirium tremens was the result of the too sudden breaking off from indulgence in alcohol, led to its treatment by regular and often large doses of stimulants, a practice fraught with mischievous results, since however much the delirium appeared to be thus calmed for the time, the continuous supply of the poison which was the original source of the disease inflicted serious damage upon the brain, and led in many instances to the subsequent development of insanity. The former system of prescribing large doses of opium, with the view of procuring sleep at all hazards, was no less pernicious. In addition to these methods of treatment, mechanical restraint of the patient was the common practice.

The views of the disease which now prevail, recognizing the delirium as the effect at once of the poisonous action of alcohol upon the brain and of the want of food, encourage reliance to be, placed for its cure upon the entire withdrawal, in most instances, of stimulants, and the liberal administration of light nutriment, in addition to quietness and gentle but firm control, without mechanical restraint. In mild attacks this is frequently all that is required. In more severe cases, where there is great restlessness, sedatives have to be resorted to, and many substances have been recommended for the purpose. Opiates administered in small quantity, and preferably by hypodermic injection, are undoubtedly of value; and chloral, either alone or in conjunction with bromide of potassium, often answers even better. Such remedies, however, should be administered with great caution, and only under medical supervision.

Stimulants may be called for where the delirium assumes the low or adynamic form, and the patient tends to sink from exhaustion, or when the attack is complicated with some other disease. Such cases are, however, in the highest degree exceptional, and do not affect the general principle of treatment already referred to, which inculcates the entire withdrawal of stimulants in the treatment of ordinary attacks of delirium tremens.


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Simple English

Delirium is a medical term. Doctors use it to describe patients who have lost parts or all of their ability to focus attention. Such people may also have problems to concentrate, or to remember things or people. Delirium is a medical symptom. It is not a disease. It can have many causes which are:

Deliria are always a medical emergency, because it is impossible to predict how they develop. Worst-case scenarios include cardiac arrest, and malfunctions of the metabolism. In order to be able to treat a delirium, its cause must usually be found. In the case of alcoholism, the most common cause for a delirium is the withdrawal of alcohol. This condition is known as Delirium tremens.








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