What symptoms indicate senile insanity, and how to treat it. Delirium (not caused by alcohol or other psychoactive substances)

This is how Mother Nature decreed that a person is forced to gradually grow old. Approaching a new stage of his life, a person sometimes thinks about what awaits him next. At best, the rest of your days pass in good health and monotonous everyday worries. And at worst, senile delirium sets in, which can turn your whole life upside down and bring considerable worries to loved ones.

What is this disease? The aging of the body is accompanied by irreversible changes in the functioning of all organs and systems, especially the brain. Against the background of internal diseases, alcoholism, and injuries, people begin to develop dementia (dementia), characterized by the loss of acquired skills and knowledge. Senile delirium is one of the symptoms of dementia, accompanied by scanty visual hallucinations.

Manifestations of delirium increase gradually and change throughout the day, worsening with the onset of darkness. To the most frequent symptoms This disease can be attributed to:

poor concentration;
inability to think critically;
repetitive movements;
weak, sedentary hallucinations;
anxiety;
nightmares.

Irreversible changes also occur in the internal organs, leading to impaired urination, sweating, tachycardia, increased blood pressure and muscle weakness.

Elderly patients, when a delirious state occurs at night, become agitated, fussy, and disoriented in space. They begin to remember past events, can speak incoherently quietly or get ready to travel with business activity, while there is no feeling of fear and uncertainty. Movements become small in amplitude, tremors of the arms, jaw and torso increase.

With a more severe course of the disease, some patients, in an excited, darkened state, begin to perform actions related to everyday or professional life: sewing, cleaning, turning the steering wheel, typing. Verbal contact with them is impossible at this moment. The deeper stage of delirium is characterized by a lack of response to external stimuli, a gaze directed into space, delusional sounds and phrases.

An attack of the disease of the first and second stages can pass within a day and end with asthenia in combination with depression. The memory of the experienced state will be fragmentary or completely absent. In severe cases, the patient cannot be brought out of this attack, and he may die.

Causes of senile delirium

The disease is based on the development of atrophic processes in the brain that occur after 65 years. Senile dementia, complicated by any intellectual disease, is a trigger for professional and persistent delirious hallucinations. Since the disease is closely related to increasing dementia, the reasons for their appearance are the same.

In medicine, several of them are distinguished:

hereditary mental illnesses;
serious pathologies of internal organs and systems;
genetic abnormalities;
infections.

Important reasons include the negative effects of drugs, alcohol and tobacco on the body. People leading wrong image lives are at risk for developing this pathology.

Diagnosis of the disease

To make an accurate diagnosis and select a hospital profile, it is necessary to collect as completely as possible (with the involvement of relatives and neighbors) and conduct the examination correctly.

When collecting data about a patient's life, it is important to find out the following points:

the presence of previous disorders of consciousness;
heredity for mental illness;
tendency to use drugs, psychoactive substances and alcohol;
the presence of chronic somatic diseases, acute infections;
previous injuries and surgeries;
facts of hospitalization in psychiatric hospitals.

The purpose of an objective examination is to determine the severity and nature of neurological and vegetative-somatic disorders. You need to try to establish contact with the patient by asking simple questions. The assessment of answers well characterizes specific thinking disorders. Hospitalization in a hospital is carried out according to regulated protocols for the treatment of this disease.

How to deal with the disease?

Treatment of senile delirium consists of eliminating the cause of its development (fighting infection, somatic pathologies). Unfortunately, medicines Medicine has not yet invented a cure for senile dementia, which provokes delirium. Therefore, in such situations, drugs are used that weaken and stop the attack.

Drug therapy includes the administration of intravenous glucose, ascorbic acid, and B vitamins. Sedatives or tranquilizers (propazine, trioxazine) are used to relieve agitation.

Basically, such patients need quality care and normal mode nutrition. They should be protected from exposure irritating factors which may cause the condition to worsen. In mild forms of delirium, only care and communication will help relieve the condition. Self-medication in this situation is strictly prohibited.

We all dream of magic pills that will defeat inevitable aging once and for all. It's no secret that today many older people maintain a beautiful appearance and high physical activity. And yet, the fear of senile mental decline is familiar to almost everyone. What to do if a loved one has symptoms of age-related brain disorders - senile psychosis?

Senile psychosis in Latin comes from the word “senilis” (Latin: “senile”) and refers to diseases of old age. With age, not only physiological, but also mental activity a person gradually weakens more and more. This process is natural for the elderly, but excessive loss of consciousness is pathological.

Dementia, prolonged depressive states, paranoid manifestations are considered the main signs of this dangerous disease. It has symptoms of schizophrenia and senile dementia. However, the concept of senile psychosis presupposes only partial, and not total clouding of consciousness. In accordance with the World Health Organization classifier, it is called “delirium due to dementia” and ICD-10 code F05.1

Causes

A number of different factors can provoke the development of senile psychosis:

Development of senile dementia, manic – depressive syndrome associated with age-related brain pathology: Alzheimer's disease (death of brain cells), Pick's disease (destruction and atrophy of the cerebral cortex).
Use of anesthesia during operations. In the postoperative period, the risk of acute brain syndrome in an elderly person it is especially large.
Genetic predisposition.
Experienced emotional trauma resulting in severe post-traumatic stress disorder.
A number of somatic pathologies: work disorders respiratory system, genitourinary organs, heart failure, hypovitaminosis.
Chronic insomnia, physical inactivity, systematically poor nutrition, visual and hearing impairment.

Often, older people do not even consult a doctor with these symptoms, considering them to be normal manifestations of age. This leads to delayed treatment, which can give rise to senile disorders reason.

Although adherence to the principles of a healthy lifestyle, unfortunately, does not guarantee the absence of health problems in old age. Many older people have experienced age-related disorders of consciousness even with careful attention to healthy eating, regimen and timely medical examinations.

Fortunately, not every elderly person develops senile psychosis. In addition, with early treatment, deviations often do not develop into more severe pathologies.

Main symptoms

Primary signs include severe constant fatigue, insomnia, and loss of appetite. An elderly person begins to demonstrate helplessness and becomes lost in reality. The main symptoms of the disease include:

clouding of consciousness, sometimes to the point of complete deformation of the mental state of the individual;
violation of orientation in space;
musculoskeletal disorders;
complete or partial amnesia (memory loss);
The acute form is characterized by fussy motor agitation with simultaneous loss of coordination of movements.

All this leads to the fact that old man is not able to take care of himself, and may also not realize the need to see a doctor.

People over 60 years of age are at risk, but sometimes senile involutional psychoses are observed at the age of 50 years and older.

There is a separate group of pathologies (presenile), which develop in a similar way and with the same symptoms, but already at the age of 45–60 years. Studies have found that presenile and senile psychoses are observed much more often in women than in men.

Forms and types of senile psychosis

Medicine distinguishes between acute and chronic phase diseases. Acute pathology occurs more often. It is characterized by a sudden onset and vivid symptomatic manifestations.

Paranoid delusions are a frequent signal of impaired consciousness. For example, the patient becomes aggressive towards the people around him, and is sure that they want to harm him or his property. Before this (1-3 days), as a rule, loss of appetite and weakness, insomnia, and spatial disorientation are noted. As the deformation of consciousness develops, clouding of thinking and anxiety progress, and hallucinations may appear.

Pathology in the acute phase lasts from several days to weeks, while the general physical state getting worse. Symptoms may occur intermittently or continuously. It is important for the patient’s family and friends to understand the outcomes of acute senile psychoses possible without immediate assistance doctors: this is a strong and severe clouding of the mind, causing harm to oneself and others.

Chronic pathology mainly occurs with mild symptoms of clouding of consciousness:

An elderly person willingly and a lot tells a large number of non-existent events and false memories. He sees all this in the present tense.
Hallucinations become regular. The pictures of hallucinations are very believable, endowed with volume and color. The patient sees people, animals, talks to them, and experiences imaginary life situations. He experiences tactile hallucinations: itching, burning, pain. In this case, the patient points to causes of discomfort that do not exist in reality: insects, sand, crumbs, etc.
Paranoid delusion.
Hallucinatory-paranoid syndrome. Delusions are combined with hallucinations, and symptoms of schizophrenia may appear. It can develop over a long period of life (up to 10 - 15 years).
Depression ( general symptom V clinical picture most mental disorders), accompanied by apathy and weakness. The sick person feels the unattractiveness of the future and hopelessness. Deterioration of the condition leads to high anxiety and severe mental agitation.

Suppression of the productive functions of an elderly person’s body can go unnoticed by others, manifesting itself only in minor memory disorders. However, even in this case, without the supervision of a specialist, the patient is in serious danger.

Diagnosis, treatment and prevention

It is important to distinguish the disease from classic depression, senile dementia, and manic-depressive psychosis. On initial stages examinations must also exclude vascular disorders, oncology and other pathologies. Diagnosis is carried out on the basis of the clinical picture, as well as additional research(for example, computed tomography).

It is impossible to successfully cure senile psychosis on your own or with folk remedies. You should immediately consult a psychiatrist. For the treatment of acute psychoses in old age, the patient needs hospitalization; only in the hospital will he receive full-fledged medical and nursing care. Taking into account all manifested symptoms, treatment is prescribed strictly individually, in accordance with the full clinical picture of concomitant diseases.

Medicines used (the course of therapy is carried out strictly under the supervision of a doctor):

Antidepressants in combination with sedatives(for the correction of depressive conditions).
Neuroleptics (normalization anxious behavior, confusion).
Neuroleptics in combination with tranquilizers (for severe anxiety, insomnia).

It is useful to keep the older person occupied with simple mental and physical exercise, as this stimulates the brain and reduces the risk of recurrence of acute psychosis. Psychological support for the family and proper home care are also of great importance.

In the video, psychiatrist Mikhail Tetyushkin examines a specific case of the disease. The doctor comments on symptoms and treatment methods, and also gives recommendations to loved ones on how to interact with a sick person.

Conclusion

Unfortunately, modern medicine still does not know methods that completely eliminate senile dementia and brain atrophy. If medical assistance is provided on time, acute senile psychosis, not accompanied by prolonged clouding of consciousness, is often curable.

The chronic phase of senile psychosis is often fraught with serious consequences: progressive personality disorders, even suicide. Its danger is that clear symptoms often appear too late - the diagnosis is not made early stage, medical measures were not taken on time. Therefore, in terms of cure, the disease has an unfavorable prognosis.

Prevention of the development of senile psychoses includes regular medical examinations, avoidance of severe stressful situations and emotional overload, alcohol and drug effects on the body in old age.

If your elderly relative begins to show symptoms of senile dementia and other “age-related” disorders, it is important not to panic, but to take the necessary measures in time. Do not forget that as old age approaches, our relatives and friends increasingly need our attention, care and care.

Delirium is a general clinical syndrome, characterized by confusion and “acute cognitive dysfunction.” The word "delirium" was first used as a medical term as early as the first century AD to describe mental disorders occurring during fever or head injury. Doctors tried to describe delirium with the following terms: “acute confusion”, “acute cerebral failure”, “toxic metabolic encephalopathy”, etc. Over time, delirium began to be understood as a short-term, reversible syndrome, which is partly acute in its occurrence and flickering in its symptoms.

Clinical experience and recent research have shown that delirium can become chronic or fatal. In older patients, delirium may be a key component in the cascade of events that lead to a downward spiral of “functional decline” and ultimately death.

The overall prevalence of delirium in the general population is only 1-2%. Postoperative delirium is recorded in 15%-53% surgical patients over 65 years of age, and among elderly patients admitted to the department intensive care, the incidence of delirium can reach 70-87%.

Delirium affects, according to experts, from 14% to 56% of all hospitalized patients. psychiatric hospitals elderly patients. At least 20% of the 12.5 million patients over 65 years of age who are admitted to U.S. psychiatric hospitals each year have complications during their hospitalization due to delirium.

The causes of delirium are varied and they often reflect the pathophysiological consequences of acute somatic illness, medicinal effect or complications. In addition, delirium develops due to a complex interaction between various factors risk. The development of delirium often depends on a combination of predisposing, as it were, background factors, such as underlying dementia or severe somatic illness, and the acceleration of the development of delirium depends on frequently changing factors, such as medication sedatives, infections, abnormal test results or surgery. Among elderly patients, one of the most important factors risk of delirium is dementia (two thirds of all cases of delirium in this age group occur in patients with dementia). Research has shown that delirium and dementia are associated with decreased cerebral blood flow or metabolism, cholinergic deficiency, and inflammation, and these similar etiologies may explain the close relationship between these pathophysiological factors.

Potentially changing risk factors for delirium

Sensory impairments, such as auditory or visual
Immobilization (catheters or restraints)
Medicines (such as sedatives sleeping pills, drugs, anticholinergic drugs, corticosteroids, polypharmacy, alcohol or other drug deprivation syndrome)
Acute neurological diseases (for example, acute stroke - usually right parietal, intracranial hemorrhage, meningitis, encephalitis)
Intercurrent illnesses (eg, infections, iatrogenic complications, severe acute medical illness, anemia, dehydration, poor nutrition, fractures or trauma, HIV infection)
Metabolic disorders
Surgical interventions
Environment (eg, intensive care unit admission)
Expressed emotional feelings
Moderate sleep insufficiency (deprivation)

Permanent risk factors
- Dementia or cognitive impairment
- Age > 65 years
- History of delirium, stroke, neurological disease such as ataxia
- Multiple comorbidities
- Male
- Chronic renal or liver failure

Current evidence suggests that drug toxicity, inflammation, and acute stress reactions may to a large extent contribute to disruption of neurotransmission of central mediators nervous system and, ultimately, the development of delirium. Systemic inflammation may result from systemic infection, trauma, or surgery. The cholinergic system plays a key role in cognitive function and it is therefore not surprising that there is extensive evidence supporting the role of cholinergic deficits in the genesis of delirium. Anticholinergic drugs can cause delirium and often contribute significantly to the delirium observed in hospitalized patients. Increased acetylcholine levels due to the use of cholinesterase inhibitors such as physostigmine can cause delirium. Serum anticholinergic activity, which reflects the anticholinergic effects of both endogenous and exogenous drugs and their metabolites, has been shown in some studies examining the dynamics of delirium. Other neurotransmitter abnormalities associated with delirium include increased dopaminergic brain activity and a relative imbalance between the dopaminergic and cholinergic systems. The use of antiparkinsonian drugs can also cause delirium, and dopamine antagonists such as haloperidol are effective in treating symptoms of delirium. It is assumed that the neurotransmitters glutamate, γ -aminobutyric acid, 5-hydroxytryptamine (5-HT), and norepinephrine are also associated with delirium.

Delirium - common reason and a serious complication of hospitalizations and has important consequences for the patient, both from a functional and economic point of view
Delirium is potentially preventable and treatable, but major barriers, including underestimation of the severity of the syndrome and poor understanding of its underlying pathogenesis, hinder its development. successful methods treatment
Neuroimaging revealed structural changes with delirium, including cortical atrophy, ventricular dilatation and white matter damage, which can be considered both predictors of delirium and its consequences
Evidence suggests that impaired neurotransmission, inflammation, or acute stress reactions may contribute to the development of delirium
Delirium is not always short-lived or reversible and may lead to long-term cognitive changes

There is experimental and clinical evidence to suggest that trauma, infection, or surgery may lead to increased production of proinflammatory cytokines, which may precipitate delirium in sensitive patients. Peripherally secreted cytokines can provoke exaggerated responses from microglia, thereby causing significant inflammation in the brain. Proinflammatory cytokines can significantly influence the synthesis or release of acetylcholine, dopamine, norepinephrine and 5-HT, thereby disrupting neuronal communication and they can also have direct neurotoxic effects. In addition, proinflammatory cytokine levels have been shown by a number of researchers to be elevated in patients with delirium. delusional. The presence of low-grade inflammation associated with chronic neurodegenerative changes in the brains of patients with dementia may explain why these patients are at increased risk of delirium. The importance of high cortisol levels associated with acute stress has been suggested for the onset and/or maintenance of delirium. Steroids may cause deterioration of cognitive function (steroid psychosis), although not in all patients receiving high doses steroids may develop a state of delirium. In elderly patients, regulation feedback cortisol levels may be disrupted, leading to more high levels baseline cortisol and thereby predisposes this population to delirium. A number of studies have found elevated cortisol levels in patients who developed postoperative delirium. Other studies have found an abnormal decrease in cortisol in a dexamethasone suppression test, a result that indicates dysregulated cortisol leading to increased cortisol levels in patients with delirium. The role of cortisol in the development of delirium, however, deserves further study. Delirium associated with direct neuronal damage can be caused by various metabolic or ischemic lesions brain. Hypoxia, hypoglycemia and various metabolic disorders can cause energy deprivation, which leads to impaired synthesis and release of neurotransmitters, as well as impaired distribution nerve impulses along the nerve networks involved in the processes ensuring the functioning of the cognitive sphere. In elderly patients with delirium of various etiologies, Imaging showed cortical atrophy in the prefrontal cortex, temporal cortex in the nondominant hemisphere, and atrophy of deep structures, including the thalamus and basal ganglia. Other features that are observed on imaging include: ventricular dilatation, white matter changes, and basal ganglia lesions. These changes likely reflect a state of increased vulnerability of the brain to any negative influence and an increased susceptibility to the development of delirium. A number of studies, however, have not identified any significant abnormalities in CT scans of patients with delirium. To date, relatively few studies have used functional imaging to examine brain changes in delirium. One prospective study of hospitalized patients with delirium of various etiologies used single photon emission tomography (SPECT) and found frontal and parietal hypoperfusion in half of the patients. Other studies that have used SPECT imaging, primarily in patients with hepatic encephalopathy (a form of delirium caused by liver failure), have identified various types of hypoperfusion, including involvement of the thalamus, basal ganglia, and occipital lobes. In one study with Xenon-enhanced CT, global perfusion was decreased during delirium. Rapid progress in the development of neuroimaging technologies offers exciting prospects for the use of new methods to elucidate the mechanisms of delirium. These techniques include volumetric MRI, which may be useful in assessing the rate of brain atrophy following delirium or determining threshold levels of atrophy that predispose patients to delirium. Diffusion tensor imaging and tractography can help assess damage to the fibers of the neural tracts that connect different areas brain Arterial spin perfusion measures blood flow and can be used to assess both cerebral perfusion and response to medications. MRI can also be used to assess the integrity of the blood-brain barrier and its role in the development of delirium. It appears that the symptoms of delirium are quite variable, but it can be classified into three subtypes - hypoactive, hyperactive and mixed - based on the characteristics of psychomotor behavior. Patients with hyperactive delirium show signs of restlessness, agitation, and increased anxiety and often experience hallucinations and delusions. In contrast, patients with hypoactive delirium, accompanied by lethargy and sedation, are slow to respond to questions and show limited spontaneous activity. The hypoactive form is most common in older patients, and these patients are often overlooked or misdiagnosed as having depression or a particular form of dementia. Patients with mixed delirium exhibit both hyperactive and hypoactive features. It has been suggested that each subtype of delirium may result from a distinct pathophysiological mechanism and that each variant of delirium may have a different prognosis.

Are common diagnostic criteria delirium

(A) Impaired consciousness (i.e., decreased clarity of awareness environment) with a reduced ability to focus, maintain, or shift focus of attention
(B) Cognitive changes (eg, memory deficits, confusion, speech impairment) or development of perceptual impairments that are not associated with dementia
(C) The disorder develops over a short period of time (usually hours to days) and typically fluctuates in severity throughout the day

Criteria for delirium that has developed due to deterioration general condition health

(D) Evidence from history, physical examination, or laboratory testing indicates that the disorder is caused by direct physiological effects of general health conditions

For delirium due to substance intoxication

(D) Evidence from history, physical examination, or laboratory testing indicates that either (1) symptoms in criteria A and B are due to substance intoxication, or (2) drug use is etiologically related to delirium

For delirium, "multiple" etiologies

(D) History, physical examination, or laboratory research indicate that delirium has more than one etiology

Postoperative delirium may develop on the first or second postoperative day, but the patient is often hypoactive and therefore may go undetected. Delirium is difficult to recognize in the intensive care unit because standard cognitive tests of attention are often not used because patients are intubated and unable to answer questions verbally.

ICD-10- F 05

Delirium not caused by alcohol or other psychoactive substances is most common in therapeutic and surgical departments, where these patients can range from 10% before 30% all patients, predominantly in intensive care units and burn centers. U 10–15% in elderly people, delirium is noted upon admission to the hospital, even in 10–40% develops during your stay there. Delirium is also common in children or, conversely, in the elderly, as well as in persons with a history of organic brain pathology. Delirium may occur in children unexplained changes behavior, the real reason which becomes obvious only with a thorough examination of the state of cognitive functions.

!!! REMEMBER: Changes in mental status may be the most noticeable indicators of the severity of the underlying somatic disease, especially in people late age, in whom delirium is often the most early manifestation infectious disease or coronary disease hearts.

For 25% sick delirium ends in death for 3-4 months, only partly due to the underlying disease (increased risk of status epilepticus, cardiovascular complications).

!!! REMEMBER: Delirium - emergency, which requires emergency help and immediate and complete medical examination aimed at identifying the cause of delirium.

ETIOLOGY

Delirium can be considered as general syndrome various brain lesions.

Delirium is caused by a number of factors that can interact and potentiate each other:
individual characteristics: age, previous cognitive deficit, combination with serious illnesses, previous episodes of delirium, premorbid personality characteristics
organic inferiority of brain structures
action toxic agents, including non-psychoactive pharmacological
treatment with multiple drugs
use of psychoactive drugs or alcohol
reception special drugs that can cause problems: benzodiazepines, anticholinergics, narcotics
situational factors: unusual surroundings, dark blindfolds after cataract surgery, etc.
personal factors: excessive fear of medical and surgical interventions etc.
factors of the operating period: course postoperative period, type of operation, urgency of operation
stress factors general order: postoperative pain, hypoxia, ischemia, blood loss, insomnia, electrolyte imbalance, infection, hyperthermia

CLINIC

Prodromal phenomena (as a rule, may precede the onset of acute symptoms) :
restlessness, anxiety during the day, increased sensitivity to sound and light
short periods of sleep are accompanied by nightmares, from which patients wake up in a cold sweat
when falling asleep in a state of drowsiness, hallucinations often occur: images of deceased relatives, a figure in black, etc. appear before the eyes. -hypnagogic hallucinations

!!! REMEMBER: The main symptom of delirium is impaired consciousness.

Violation of allopsychic orientation and perception. The patient loses the ability to navigate the surrounding reality, is unable to distinguish it from dreams, nightmares that become especially vivid, and often illusions and hallucinations (usually unsystematized and not auditory, but visual, olfactory, tactile); visual hallucinations of a frightening, often zooptic nature, which can be stimulated by pressure on eyeballs; hallucination is preceded by illusions and pareidolia, as well as visualized imagination; it is difficult for the patient to correctly recognize others, and there is increased distractibility to external stimuli. Despite the lack of orientation in time and place, consciousness of one’s own personality, as a rule, remains intact.

!!! REMEMBER: Despite the lack of orientation in time and place, consciousness of one’s own personality, as a rule, remains intact.

Impaired cognitive functions. The main disorder in the cognitive sphere is considered to be pathological changes in attention. Thinking becomes incoherent, slow and more concrete, higher mental functions and abstract thinking are lost. The speech is monosyllabic, abrupt, and reflects fear and associated false perceptions. Patients express delusional ideas, often relationships and persecutions. Fluctuations in the severity of cognitive disorders during the day with their highest intensity at night and early morning hours are characteristic clinical feature delirium. Lucid intervals, in which the patient maintains orientation in the surrounding reality, last from several minutes to several hours.

!!! REMEMBER: Fluctuations in the severity of cognitive disorders during the day with their highest intensity at night and early morning hours are a characteristic clinical feature of delirium.

Motor sphere. Characterized by sudden fluctuations in motor skills from physical inactivity to severe agitation. The patient's behavior corresponds to the fear he experiences and the content of the hallucinations. Characteristic sudden fluctuations in behavior from psychomotor retardation to psychomotor agitation.
Autonomic dysfunction. Autonomic disorders are common - vasomotor play, sweating, sudden fluctuations heart rate, nausea, vomiting, fever. The normal rhythm of sleep and wakefulness is lost.

Emotional sphere: the dominant affect is fear and anxiety, caused by the frightening content of perception deceptions, often prompting the patient to dangerous actions, often associated with attempts to escape from an imaginary threat.

!!! REMEMBER: Mood disturbances are typical but not specific to delirium.

Memory impairment. Memory impairments manifest themselves in impairment of immediate memorization and short-term memory with relatively intact long-term memory. After recovery from delirium, only partial memories, reminiscent of nightmares, are retained.

!!! Due to the wide range of symptoms The clinical picture of delirium can be very varied and is therefore often misdiagnosed.- depending on the predominant syndrome and the nature of its development - dementia or functional mental disorders.

CURRENT and FORECAST: Delirium is characterized by an acute onset (sometimes sudden, but often developing over several hours or days), a fluctuating course (symptoms tend to wax and wane over the course of each day, with worsening usually occurring at night), and transitory nature(in most cases, delirium resolves within a few days or weeks). Often the clinical picture also includes a prodromal stage (see above). Delirium is reversible with timely attention to etiological factors. The course without therapy can be accompanied by both spontaneous recovery and further progression to a state of dementia or other organic brain syndrome.

DIAGNOSIS

To be diagnosed, the condition must meet the following criteria (ICD-10):
disturbance of consciousness, accompanied by unclear perception of the environment, decreased concentration and switchability of attention, impaired orientation in time, place and one’s own personality
impairment of immediate memory and short-term memory with relatively intact long-term memory
presence of at least one of the following psychomotor disorders:
1. rapid, unpredictable changes in physical inactivity and hyperactivity
2. slow reaction
3. slowing down or speeding up speech
4. increased readiness for anxiety and panic reactions
disturbance of the rhythm of sleep and wakefulness manifested by at least one of the following symptoms:
1. sleep disturbances, reaching complete insomnia, or the opposite normal rhythm sleep and wakefulness,
2. increase in symptoms at night,
3. nightmares, which after awakening can continue in the form of illusions or hallucinations;
sudden onset And fluctuations in severity symptoms during the day
objective data on the presence of cerebral or other pathology(non-substance-related) that may cause symptoms

Confusion Assessment Method - CAM (Confusion Assessment Method)- contains an operationalization of key elements of DSM–III–R and has high sensitivity and specificity, allowing the diagnosis of delirium.

The diagnosis of delirium is established when there is (1) + (2) + one of the signs (3) or (4) :

(1) Acute onset and undulating course(data about a sudden change in the patient’s mental state compared to the baseline status, and the severity of the condition changes during the day)
(2) Attention disorders(the patient has difficulty concentrating, for example, he is easily distracted or loses the thread of the conversation when communicating)
(3) Disorganization of thinking(the patient has disorganized or incoherent thinking, which is manifested by inconsistent or inappropriate statements during conversation, as well as unclear or illogical train of thought)
(4) Change in level of consciousness(the patient's level of consciousness is assessed as different from normal; for example, there is hyperactivation of consciousness or increased level wakefulness, signs of lethargy or drowsiness, stupor or coma)

DIFFERENTIAL DIAGNOSIS

Differential diagnosis is carried out mainly with other mental disorders, while establishing an accurate diagnosis is even more complicated by the fact that delirium is often combined with other pathology.

In approximately two thirds of cases, delirium develops due to dementia, but the two disorders can usually be differentiated. Unlike dementia, delirium develops more acutely and has a shorter duration (usually less than a month). Frequent fluctuations in state during the day, which are typical for delirium, are not typical for dementia. Unlike delirium, with dementia in initial stages orientation, attention, perception, and the rhythm of sleep and wakefulness characteristic of age are preserved; excitability is less pronounced. The content of thinking in delirium is disorganized, while in dementia it is rather impoverished. In delirium, only short-term memory is affected, while in dementia, both short- and long-term memory are impaired. Delirium can also develop in the context of dementia, this case is known as demented dementia.

Delirium must be distinguished from evening confusion - This term is usually used to refer to the relatively mild fluctuations in mental status seen in dementia (although the relationship between evening confusion and delirium remains to be clarified).

At schizophrenia, unlike delirium, consciousness and orientation are usually preserved. Perceptual disturbances in schizophrenia are more related to auditory deceptions; they are more constant and systematized than in delirium. In cases of short-term reactive psychoses, the global cognitive impairment characteristic of delirium is absent. Delirium can be distinguished from feigning behavior by the detection of volitional control of symptoms and EEG data (with delirium, a diffuse slowing of background EEG activity is often noted).

The clinical picture of delirium may resemble that of functional mental disorders . The emotional and behavioral disturbances of delirium are easily confused with adaptation reactions, especially in patients who have suffered severe mental trauma or have cancer.

Difficulties often arise in differentiating delirium from depression, especially in women and in patients with hypoactive and lethargic manifestations of delirium. Most of the symptoms of a large depressive disorder(eg, psychomotor retardation, sleep disturbances, and irritability) may also occur with delirium, but the onset of a depressive episode is usually less acute and the clinical picture is dominated by mood disorders. In addition, cognitive impairment in depression is usually more reminiscent of dementia (“depressive pseudodementia”) than delirium.

Hyperactivity in the clinical picture of delirium resembles similar disorders observed in anxiety disorders , agitated depression And manic state .

The situation is further complicated by the fact that the development of delirium can be triggered by dehydration resulting from impaired water metabolism in patients with severe depression who are unable to independently monitor the timely intake of fluids.

!!! REMEMBER: Making an accurate diagnosis of delirium is very important, since an erroneous diagnosis of depression leads to a delay in providing adequate care and to the prescription of antidepressants, most of which have anticholinergic properties and can contribute to the worsening of the delirium.

TREATMENT

Therapy is determined by detection and intervention on etiological factors with a simultaneous impact on specific symptoms of delirium.

It is important to avoid both deficiency and excess external stimuli . It is preferable for the patient to stay in a quiet single room with soft, dim lighting to facilitate patient orientation. Many supportive measures, such as attention to noise, lighting and mobility, reflect the basic requirements of a good therapeutic environment, protect against the development of delirium and should be routinely applied in all health care settings. Other tasks specifically related to the symptoms of delirium, such as helping patients regain their orientation, should be particularly detailed in the treatment plans. Nurses trained in the management of patients with delirium have been shown to improve patient outcomes by reducing risk factors, better recognizing the condition, and promoting standardization of care.

Family members or caregivers can answer questions about what it was like mental condition patient before illness, and facilitate efforts to reassure the patient and restore his or her orientation.

Educating family members about delirium is important because caregivers, being distressed and poorly informed, can cause distress in the patient. Delirium may herald the end stage of the disease, and the patient may be remembered by loving relatives as “crazy” or restless if everything is not tactfully explained to them. Because symptoms of delirium may not have completely resolved by the time a patient is discharged from hospital, family members play a critical role in planning and monitoring care.

Drug treatment

Drug treatment for delirium requires careful balance between effective treatment of symptoms and possible side effects.

Usage psychotropic drugs complicates ongoing mental status assessment, may impair the patient's ability to understand and cooperate with treatment, and is associated with an increased risk of falls. Therefore, it is important to clarify the indications for prescribing medications in the treatment of delirium.: Which task is primary - to mitigate the manifestations of delirium or to curb inappropriate behavior?

Sedative components may reduce agitation, but may also worsen cognitive impairment. A small proportion of patients require sedation for their own protection. To a lesser extent, drug therapy is needed in cases where delirium is detected during screening, but there are too few studies on effectiveness pharmacological prevention in high-risk populations.

Antipsychotic drugs

Antipsychotics are the cornerstone pharmacological treatment. Neuroleptics reduce a number of symptoms and are equally effective in patients with hypo- and hyperactive clinical type, and usually improve cognitive function. Their onset of action is rapid, with improvement usually occurring within hours or days, and thus occurs before the underlying pathology of delirium is cured.

Antipsychotics are superior to benzodiazepines in the treatment of delirium due to causes other than alcohol withdrawal or sedative hypnotics.
Chlorpromazine, droperidol, and haloperidol have similar efficacy, but haloperidol is preferred because it has fewer active metabolites, limited anticholinergic effects, less sedative and hypotensive effects, and can be administered by multiple routes.
Although the use of potent antipsychotics such as haloperidol is associated with an increased risk of extrapyramidal effects, the actual incidence observed in studies is low. Besides, intravenous use haloperidol appears to be less dangerous in terms of the development of extrapyramidal disorders in patients with delirium.

Droperidol is more suitable in cases where a faster onset of action and a greater level of sedation are required.

Pimozide is a potent calcium antagonist and may be useful in the treatment of delirium associated with hypercalcemia.

Dose of antipsychotic drugs determined by the route of administration, the patient’s age, the severity of arousal, the patient’s risk of developing side effects and the conditions in which therapy is carried out. Low dose haloperidol for orally(1-10 mg/day) causes a reduction in symptoms in most patients.

!!! REMEMBER: To relieve agitation, antipsychotics (drugs of choice) are prescribed, which do not have excessive sedative effects, the risk of developing arterial hypotension, or side effects on the cardiovascular system. Among antipsychotics, the drug of choice is haloperidol; the initial dose varies from 2 to 10 mg IM; this dose is re-administered every hour if the patient remains agitated. As soon as the patient calms down, you should switch to taking haloperidol orally. To achieve the same therapeutic effect, the dose of drugs taken orally is increased by 1.5 times compared to the dose administered parenterally. In most cases, 10–60 mg of haloperidol per day is sufficient to achieve the effect.

Benzodiazepines

Benzodiazepines are the first choice for delirium associated with seizures, and they are also a useful adjunct to treatment for patients who are intolerant to antipsychotic medications because they allow dose reduction. The therapeutic objectives of treatment with these drugs are quite clear, since with increasing doses their anxiolytic, sedative and hypnotic effects increase. Benzodiazepines may both protect against delirium and be a risk factor for its development; This emphasizes the need for judicious use in patients dependent on alcohol or benzodiazepines.

Lorazepam has a number of advantages due to its sedative properties, rapid onset of action, short duration of action, low risk of accumulation, absence of large active metabolites; its bioavailability is more predictable when intramuscular injection. Low doses should be used in elderly patients, in those with liver disease, and in those receiving drugs that increase oxidative metabolism in the liver (for example, cimetidine and isoniazid). The recommended upper dose limit for lorazepam is 2 mg every 4 hours. Administration of sufficient initial doses reduces the risk of paradoxical arousal (i.e., disinhibition with increased behavioral disturbances).

!!! REMEMBER: Benzodiazepines are not recommended to be prescribed during the day: their sedative effect can increase the patient’s disorientation. However, in case of liver failure, benzodiazepines are preferable, since the likelihood of developing hepatic coma when using them less than when using other drugs.

Delirium is an acute, transient, usually reversible, fluctuating disturbance of attention, perception, and level of consciousness. The causes leading to the development of delirium can be almost any disease, intoxication or pharmacological effects. The diagnosis is established clinically, using clinical laboratory and imaging studies to clarify the cause that led to the development of delirium. Treatment consists of correcting the cause that led to the delirious state and supportive therapy.

Delirium can develop at any age, but is more common in older people. At least 10% of elderly patients brought to clinics have delirium; 15% to 50% had delirium in previous hospitalizations. Delirium also often occurs in patients who are at home under the care of medical staff. When delirium develops in young people, it is usually the result of medication use or a manifestation of some systemic life-threatening condition.

The DSM-IV defines delirium as “a disturbance of consciousness and changes in cognitive processes that develops over the course of short period time" (American Psychiatric Association, DSM-IV). Delirium is characterized by easy distractibility of patients, impaired concentration, memory impairment, disorientation, and speech impairment. These cognitive disorders can be difficult to assess due to patients' inability to concentrate and rapid fluctuations in symptoms. Associated symptoms include affective disorders, psychomotor agitation or retardation, and perceptual disorders such as illusions and hallucinations. Affective disorders during delirium are extremely variable and can be represented by anxiety, fear, apathy, anger, euphoria, dysphoria, irritability, which often replace each other within a short time. Perception disorders are especially often represented by visual hallucinations and illusions; less often they are of an auditory, tactile or olfactory nature. Illusions and hallucinations often disturb patients and are usually described by them as fragmentary, vague, dream-like or nightmare images. Confusion may be accompanied by behavioral manifestations such as pulling out systems to intravenous injections and catheters.

Delirium is classified according to the level of wakefulness and psychomotor activity. The hyperactive type is characterized by pronounced psychomotor activity, anxiety, alertness, rapid excitability, loud and persistent speech. The hypoactive type is characterized by psychomotor slowness, calmness, detachment, weakening of reactivity and speech production. In a “violent” patient who attracts the attention of others, delirium is easier to diagnose than in a “quiet” patient who does not bother other patients or medical staff. Because delirium carries an increased risk serious complications and death, it is difficult to overestimate the importance of timely recognition and adequate “silent” delirium. On the other hand, in violent patients, treatment may be limited to suppressing agitation with the help of pharmacological agents or mechanical restraint of the patient, without an appropriate examination that can establish the cause of delirium.

The cause of delirium cannot be accurately determined by activity level. The patient's activity level may vary during the course of an episode or may not fall into any of these categories. However, hyperactivity is more often observed with intoxication with anticholinergic drugs, alcohol withdrawal syndrome, and thyrotoxicosis, while hypoactivity is more typical for hepatic encephalopathy. These types are distinguished on the basis of phenomenology; they do not correspond to any specific changes in the EEG, cerebral blood flow or level of consciousness. Delirium is further divided into acute and chronic, cortical and subcortical, anterior and posterior cortical, right and left cortical, psychotic and non-psychotic. In DSM-IV, delirium is classified by etiology.

Significance of the problem of delirium

Delirium is current problem health care, as this very common syndrome can cause serious complications and death. Patients with delirium spend longer in the hospital and are more often transferred to mental health facilities. Behavioral disorders may interfere with treatment. In this condition, patients often refuse to consult a psychiatrist.

Delirium and forensic psychiatry

This is a state of darkened consciousness combined with confusion, disorientation, possibly delusions, vivid hallucinations or illusions. This condition can have many organic reasons. However, the medical defense is based on that state of mind, not on what caused it. Committing a crime in a state of organic delirium is an extremely rare case. The court's decision to refer such an offender to an appropriate service will depend on the individual's clinical needs. The choice of protection option will also depend on the specific situation. It may be appropriate to plead not guilty by reason of lack of intent, or to seek a hospitalization order (or some other form of treatment) on the grounds of mental illness, or (in very severe cases) to plead insanity under the McNaughten Rules ).