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

So mother nature ordered that a person is forced to gradually grow old. Approaching a new stage in his life, a person sometimes thinks about what awaits him next. At best, the rest of the 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 ailment? 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, 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 meager visual hallucinations.

The manifestations of delirium increase gradually and change during the day, worsening with the onset of darkness. To the most common symptoms This disease can include:

poor concentration of attention;
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 pressure and muscle weakness.

Elderly patients in the event of a delirious state at night become excited, fussy, disoriented in space. They begin to remember past events, they can talk quietly incoherently or get ready for the road with business activity, while there is no feeling of fear and uncertainty. Movements become with a small amplitude, the tremor of the hands, jaw and torso increases.

With a more severe course of the disease, some patients, in an excited, clouded state, begin to perform activities related to everyday or professional life: sewing, cleaning, turning the steering wheel, typing. Speech contact with them at this moment is impossible. A deeper stage of delirium is characterized by a lack of response to external stimuli, a gaze fixed in 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 fragmented or completely absent. In severe cases, the patient can no longer be removed from 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 some intellectual disease, is the trigger mechanism for professional and mushing delirious hallucinations. Since the disease is closely associated with increasing dementia, the causes of their appearance are the same.

In medicine, there are several of them:

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

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

Diagnosis of the disease

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

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

the presence of previous disturbances of consciousness;
heredity for mental illness;
addiction to 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, asking simple questions. Evaluation of responses well characterizes specific disorders of thinking. Hospitalization in a hospital is carried out according to the regulated protocols for the treatment of this disease.

How to deal with the disease?

Treatment of senile delirium is to eliminate the cause of its development (fight against infection, somatic pathologies). Unfortunately, medicines from senile dementia, which provokes delirium, medicine has not yet been invented. Therefore, in such situations, agents are used that weaken and stop the attack.

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

In general, such patients need quality care and normal mode nutrition. They should be protected from exposure. annoying factors which may lead to worsening of the condition. In mild forms of delirium, only care and communication will help to stop 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 is no secret that today many older people maintain a beautiful appearance and high physical activity. And yet, the fear of senile delusions of reason 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 the elderly. With age, not only physiological, but also mental activity man gradually weakens more and more. This process is natural for the elderly, but excessive fading 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 implies only a partial, and not a total clouding of consciousness. In accordance with the classifier of the World Health Organization, it has the name "delirium against the background of dementia" and the ICD-10 code F05.1

Causes

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

The development of senile dementia, manic - depressive syndrome associated with age-related pathology of the brain: Alzheimer's disease (death of brain cells), Pick's disease (destruction and atrophy of the cerebral cortex).
The use of anesthesia during operations. In the postoperative period, the risk of acute brain syndrome in an elderly person is especially large.
genetic predisposition.
Past emotional trauma that caused severe post-traumatic stress.
A number of somatic pathologies: disturbances in work respiratory system, urinary organs, heart failure, hypovitaminosis.
Chronic insomnia, physical inactivity, systematically malnutrition, visual impairment, hearing impairment.

Often with these symptoms, older people do not even go to the doctor, considering them to be normal manifestations of age. This leads to delayed treatment, which can serve as a breeding ground for the occurrence 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 are faced with age-related disorders of consciousness, even with careful attention to healthy eating, regimen and timely medical examinations.

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

Main symptoms

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

obscuration of consciousness, sometimes to a complete deformation of the mental state of the individual;
disorientation in space;
disorders of the musculoskeletal system;
complete or partial amnesia (memory loss);
for the acute form, fussy motor excitation is characteristic with a simultaneous violation of coordination of movements.

All this leads to old man unable to take care of himself, may also not realize the need to see a doctor.

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

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

Forms and types of senile psychosis

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

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

Pathology in the acute phase lasts from several days to weeks, while the general physical state getting worse. Symptoms may come on either intermittently or permanently. It is important for relatives and friends of the patient to understand what outcomes of acute senile psychoses possible without immediate help doctors: this is a strong and severe obscuration of the mind, harming 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. All this he sees in the present tense.
The hallucinations become regular. Pictures of hallucinations are very believable, endowed with volume and color. The patient sees people, animals, talks to them, lives imaginary life situations. He has 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, symptoms of schizophrenia may appear. It can develop over a long (up to 10-15 years) period of life.
Depression ( general symptom V clinical picture most mental disorders), accompanied by apathy, weakness. The sick person feels the unattractiveness of the future, hopelessness. Deterioration of the condition leads to high anxiety, strong mental excitation.

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

Diagnosis, treatment and prevention

The disease is important to distinguish from classical depression, senile dementia, manic-depressive psychosis. On early stages examination, it is also necessary to exclude vascular disorders, oncology and other pathologies. Diagnosis is based on the clinical picture and additional research(for example, computed tomography).

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

Used drugs (the course of therapy is carried out strictly under the supervision of a physician):

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

It is helpful to keep the elderly busy with simple mental and physical activity, as this stimulates the brain and reduces the risk of recurrence of acute psychosis. Also of great importance is the psychological support of the family, proper home care.

In the video, psychiatrist Mikhail Tetyushkin analyzes a specific case of the disease. The doctor comments on the symptoms and methods of treatment, and also gives recommendations to relatives on interaction with a sick person

Conclusion

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

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

Prevention of the development of senile psychosis 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 has begun to show symptoms of dementia and other “age-related” disorders, it is important not to panic, but to take the necessary measures in time. Do not forget that with the approach of old age, relatives and friends need our attention, care and care more and more.

Delirium is a common clinical syndrome characterized by clouding of consciousness and "acute cognitive dysfunction". The word "delirium" was first used as medical term as early as the first century AD to describe mental disorders that occur during a fever or head injury. Doctors have tried to describe delirium in terms such as "acute confusion", "acute cerebral insufficiency", "toxic-metabolic encephalopathy", etc. symptoms.

Clinical experience and recent research have shown that delirium can become chronic or fatal. In elderly 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 older than 65 years, 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 in psychiatric hospitals elderly patients. At least 20% of the 12.5 million patients over the age of 65 who are admitted to psychiatric hospitals in the United States each year have complications during hospitalization due to delirium.

The causes of delirium are varied and often reflect the pathophysiological consequences of an acute physical 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 physical illness, and the acceleration of the development of delirium depends on frequently changing factors, such as intake sedatives, infections, abnormal test results, or surgery. Among older patients, one of the most important factors risk of delirium is dementia (two-thirds of all cases of delirium in this age group seen in patients with dementia). Studies have shown that delirium and dementia are associated with reduced 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 disturbances, such as auditory or visual
Immobilization (catheters or restraints)
Medications (such as sedatives sleeping pills, narcotics, anticholinergics, corticosteroids, polypharmacy, alcohol or other drug withdrawal syndrome)
Acute neurological disease (eg, acute stroke - usually right parietal, intracranial hemorrhage, meningitis, encephalitis)
Intercurrent illnesses (eg, infections, iatrogenic complications, severe acute medical illness, anemia, dehydration, malnutrition, fractures or injuries, HIV infection)
metabolic disorders
Surgical interventions
Environment (e.g. ICU admission)
Expressed emotional experiences
Moderately severe insufficiency (deprivation) of sleep

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

Current evidence suggests that drug toxicity, inflammation, and acute stress reactions may to a large extent contribute to the disruption of neurotransmission of mediators of the central nervous system and, ultimately, the development of delirium. Systemic inflammation may be the result of a systemic infection, trauma, or surgery. The cholinergic system plays a key role in the state of the cognitive sphere, and therefore it is not surprising that there is extensive evidence supporting the role of cholinergic deficiency in the genesis of delirium. Anticholinergics can cause delirium and often contribute significantly to the delirium seen in hospitalized patients. An increase in 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 on the dynamics of delirium. Other neurotransmitter abnormalities associated with delirium include increased brain dopaminergic 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 the 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 cause 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 obstacles, including underestimation of the severity of the syndrome and a poor understanding of its underlying pathogenesis, hinder its development. successful methods treatment
Neuroimaging revealed structural changes in delirium, including cortical atrophy, ventricular dilatation, and white matter lesions, which can be considered both predictors of delirium and its consequences
Evidence suggests that impaired neurotransmission, inflammation, or acute stress responses may contribute to the development of delirium.
Delirium is not always short-lived and reversible and can lead to long-term cognitive changes

There is experimental and clinical evidence that trauma, infection, or surgery can lead to increased production of pro-inflammatory cytokines that can cause delirium in sensitive patients. Peripherally secreted cytokines can provoke exaggerated responses from microglia, thereby causing marked inflammation in the brain. Pro-inflammatory cytokines can significantly affect the synthesis or release of acetylcholine, dopamine, norepinephrine and 5-HT, thereby disrupting neuronal communication, and they can also have a direct neurotoxic effect. In addition, pro-inflammatory levels of cytokines have been shown to be elevated in patients with delirium by a number of researchers. delirium. The presence of low-level inflammation associated with chronic neurodegenerative changes in the brains of patients with dementia may explain why these patients are at increased risk of delirium. It has been suggested that high levels of cortisol associated with acute stress are important for the onset and/or maintenance of delirium. Steroids can cause deterioration in cognitive function (steroid psychosis), although not all patients receiving high doses steroids may develop a state of delirium. In older patients, regulation feedback cortisol levels can be disrupted, leading to more high levels parent cortisol and thus 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 the dexamethasone suppression test, a finding that indicates dysregulation of cortisol leading to an increase in cortisol levels in patients with delirium. The role of cortisol in the development of delirium, however, merits 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, resulting in impaired synthesis and release of neurotransmitters, as well as impaired distribution nerve impulses on the nerve networks involved in the processes that ensure the functioning of the cognitive sphere. In elderly patients with delirium various etiologies, imaging showed cortical atrophy in the prefrontal cortex, temporal cortex in the non-dominant hemisphere, and atrophy of deep structures, including the thalamus and basal ganglia. Other features seen on imaging include: ventricular dilatation, white matter changes, and lesions in the basal ganglia. These changes probably reflect a state of increased vulnerability of the brain to any negative impact and an increased susceptibility to the development of delirium. In a number of studies, however, no significant abnormalities were found on CT scans of patients with delirium. To date, relatively few studies have used functional imaging to study brain changes in delirium. In one prospective study of hospitalized patients with delirium of various etiologies, single photon emission tomography (SPECT) was used, with frontal and parietal hypoperfusion found in half of the patients. Other studies that have used SPECT imaging, mainly 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 xenon-enhanced CT study, global perfusion was reduced during delirium. Rapid progress in the development of neuroimaging technologies opens up exciting prospects for the application of new methods to elucidate the mechanisms of delirium. These methods include MRI with volumetric analysis, which may be useful in assessing the rate of brain atrophy after delirium or determining threshold levels of atrophy that predispose patients to delirium. Diffusion tensor imaging and tractography can help evaluate 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 drug response. MRI can also be used to assess the integrity of the blood-brain barrier and its role in the development of delirium. It seems 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 associated with 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 depression or some form of dementia. Patients with mixed delirium show both hyperactive and hypoactive features. It has been suggested that each subtype of delirium may result from a specific 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 the focus of attention
(B) Cognitive changes (eg, memory deficits, confusion, speech impairment) or development of perceptual impairments that are unrelated to dementia
(C) The disorder develops over a short period of time (usually hours to days) and tends to fluctuate in severity over the course of the day

Criteria for delirium developed due to worsening general condition health

(D) Evidence from history, physical examination, or laboratory studies indicates that the impairment is caused by direct physiological consequences of general health

For delirium due to substance intoxication

(D) Evidence from history, physical examination, or laboratory findings 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, "many" 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's condition is often hypoactive and therefore may go unnoticed. Delirium is difficult to recognize in the ICU because standard attentional cognitive tests are often not used here because patients are intubated and unable to answer questions verbally.

ICD-10- F05

Delirium not caused by alcohol or other psychoactive substances is the 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. At 10–15% in the elderly, delirium is noted upon admission to the hospital, even in 10–40% develops while there. Delirium is also common in children or, conversely, in the elderly, as well as in individuals with a history of organic brain pathology. Children may experience delirium unexplained changes behavior, true reason which becomes apparent only with a thorough examination of the state of cognitive functions.

!!! REMEMBER: Changes in mental status may act as the most visible 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% delirium patients ends in death within 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 evaluation aimed at identifying the cause of the delirium.

ETIOLOGY

Delirium can be regarded 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 severe illness, previous episodes of delirium, premorbid personality traits
organic inferiority of brain structures
action toxic agents including non-psychoactive pharmacological
treatment with multiple drugs
use of psychoactive drugs or alcohol
reception specific drugs that can cause problems: benzodiazepines, anticholinergics, narcotics
situational factors: unfamiliar environment, dark bandage over the eyes after cataract surgery, etc.
personal factors: Excessive fear of medical and surgical interventions etc.
operating period factors: flow 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 events (usually may precede the onset of acute symptoms) :
restlessness, anxiety during the day, hypersensitivity 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 in the surrounding reality, 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 zoooptic nature, which can be stimulated by pressure on eyeballs; hallucinations are preceded by illusions and pareidolia, as well as visualized imagination; it is difficult for the patient to correctly recognize others, there is an increased distractibility to external stimuli. Despite the lack of orientation in time and place, the consciousness of one's own personality, as a rule, remains intact.

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

Violation of cognitive functions. Pathological changes in attention are considered the main violation in the cognitive sphere. Thinking becomes incoherent, slowed down and more concrete, higher mental functions, abstract thinking are lost. The speech is monosyllabic, jerky, it reflects fear and the false perceptions associated with it. Patients express delusional ideas, more often relationships and persecution. 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 area. Characterized by sudden fluctuations in motor skills from hypodynamia to pronounced arousal. The behavior of the patient corresponds to the fear experienced by him and the content of hallucinations. Characteristic sudden fluctuations in behavior from psychomotor retardation to psychomotor agitation.
Vegetative dysfunction. Vegetative disorders are common - the game of vasomotors, sweating, sharp fluctuations heart rate, nausea, vomiting, fever. The normal rhythm of sleep and wakefulness is lost.

emotional sphere: the dominant affect is fear, anxiety, due to the frightening content of perceptual deceptions, often prompting the patient to dangerous actions, more often associated with attempts to escape from an imaginary threat.

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

Memory disorders. Memory disorders are manifested in the violation of direct memorization and short-term memory with relatively intact long-term memory. After leaving the delirium, only partial memories remain, reminiscent of nightmares.

!!! Due to the wide range of symptoms the clinical picture of delirium can be very diverse and 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 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 stops 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 exit and further progression to the state of dementia or other organic brain syndrome.

DIAGNOSIS

To make a diagnosis, the condition must meet the following criteria (ICD-10):
disturbance of consciousness, accompanied by an ambiguity in the perception of the environment, a decrease in concentration and switching of attention, a violation of orientation in time, place and one's own personality
impairment of direct memorization and short-term memory with relatively intact long-term memory
having at least one of the following psychomotor disorders:
1. fast, unpredictable change of physical inactivity and hyperactivity
2. slow response
3. slowing down or speeding up speech
4. increased readiness for anxiety and panic reactions
disruption of the rhythm of sleep and wakefulness manifested by at least one of the following:
1. sleep disturbances, reaching complete insomnia, or the opposite normal rhythm sleep and wakefulness,
2. increase in symptoms at night,
3. nightmares, which after waking up 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 the operationalization of the key elements of the DSM-III-R and has high sensitivity and specificity, allowing the diagnosis of delirium.

Delirium is diagnosed when there is (1) + (2) + one of the features (3) or (4) :

(1) Acute onset and fluctuating course(data on a sudden change in the mental state of the patient 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, 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 the conversation, as well as fuzzy or illogical train of thought)
(4) Change in the level of consciousness(the level of consciousness of the patient is assessed as different from normal; for example, there is hyperactivation of consciousness or elevated 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 another pathology.

In about two-thirds of cases, delirium develops against the background dementia, but the two disorders can generally be distinguished. Unlike dementia, delirium develops more acutely, its duration is shorter (usually less than a month). For dementia, frequent fluctuations of the state during the day, characteristic of delirium, are uncharacteristic. Unlike delirium, dementia in initial stages orientation, attention, perception, age-specific rhythm of sleep and wakefulness are preserved; excitability is less pronounced. The content of thinking in delirium is disorganized, while in dementia it is rather depleted. With delirium, only short-term memory suffers, while with dementia, both short-term and long-term memory are impaired. Delirium can also develop in the setting of dementia, a case known as nubile dementia.

Delirium must be distinguished from evening confusion - this term is usually used to refer to the relatively mild fluctuations in mental state observed in dementia (although the relationship between evening confusion and delirium has yet to be elucidated).

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, there is no global cognitive impairment characteristic of delirium. From simulative behavior, delirium can be distinguished by the detection of volitional control of symptoms and EEG data (with delirium, a diffuse slowdown in background EEG activity is often noted).

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

Often there is difficulty in differentiating delirium from depression, especially in women and in patients with hypoactive and lethargic manifestations of delirium. Most of the symptoms of depressive disorder(eg, psychomotor retardation, sleep disturbances, and irritability) may be seen in delirium, but the onset of the depressive episode is usually less acute and the clinical picture is dominated by mood disturbances. In addition, cognitive impairment in depression usually resembles a picture of dementia (“depressive pseudodementia”) more 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 that occurs as a result of impaired water metabolism in patients with severe depression who are unable to independently monitor the timely use of fluids.

!!! REMEMBER: An accurate diagnosis of delirium is very important, as a misdiagnosis of depression leads to a delay in providing adequate care and prescribing antidepressants, most of which have anticholinergic properties and can worsen the picture of delirium.

TREATMENT

Therapy is determined by the detection and impact on etiological factors with 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 subdued light to facilitate the orientation of the patient. Many supportive measures, such as attention to noise, lighting, and mobility, reflect the basic requirements for a good therapeutic environment, protect against the development of delirium, and should be applied as standard in all hospitals. Other tasks specifically related to delirium symptoms, such as helping patients regain their bearings, should be specifically detailed in treatment plans. Nurses trained in the management of patients with delirium have already been shown to improve outcomes by reducing risk factors, better recognizing the condition, and promoting standardization of care.

Family members or caregivers can answer questions about how mental condition the patient prior to illness, and to facilitate efforts to calm the patient and restore his orientation.

Explaining the features of delirium to family members is important because caregivers, being frustrated and ill-informed, can cause distress to the patient. Delirium may herald the terminal stage of the disease, and the patient may be remembered by loving relatives as "crazy" or restless unless tactfully explained to them. Since the symptoms of delirium may not have completely disappeared by the time the patient is discharged from the hospital, relatives play a decisive role in planning and monitoring care.

Medical treatment

Medical treatment for delirium requires careful balancing between effective treatment of symptoms and possible side effects.

Usage psychotropic drugs complicates current assessment of mental status, 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 drugs in the treatment of delirium.: what is the primary task - to alleviate the manifestations of delirium or to restrain misbehavior?

Sedative components may reduce arousal, but may also exacerbate cognitive impairment. A minority of patients require sedation in order to protect themselves. To a lesser extent, drug therapy is needed in cases where delirium is detected at screening, but there are too few studies on effectiveness pharmacological prevention in high-risk populations.

Antipsychotic drugs

Antipsychotics are the cornerstone pharmacological treatment. Antipsychotics relieve a range of symptoms and are equally effective in hypo- and hyperactive patients. clinical type, and usually improve cognitive function. The onset of action is rapid, usually improving within hours or days, and thus occurs before the pathology underlying the 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 a variety of routes.
Although the use of potent antipsychotics such as haloperidol is associated with an increased risk of extrapyramidal effects, the actual incidence found in studies is low. Besides, intravenous use haloperidol seems 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 needed.

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

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

!!! REMEMBER: To relieve excitement, antipsychotics are prescribed (drugs of choice), devoid of excessive sedative action, the risk of developing arterial hypotension, and side effects on the cardiovascular system. Among antipsychotics, the drug of choice is haloperidol; the initial dose varies from 2 to 10 mg / m; this dose is repeated every hour if the patient remains agitated. As soon as the patient calms down, you should switch to taking haloperidol inside. 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 drug of first choice for seizure-associated delirium and are also a useful adjunct to treatment for patients who cannot tolerate antipsychotics because they allow dose reduction. The therapeutic objectives of treatment with these drugs are quite clear, since with an increase in their doses, anxiolytic, sedative and hypnotic effects increase. Benzodiazepines may both protect against delirium and be a risk factor for its development; this highlights 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 with 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 (eg, cimetidine and isoniazid). The recommended upper dose limit for lorazepam is 2 mg every 4 hours. The introduction of sufficient initial doses reduces the risk of paradoxical excitation (i.e., disinhibition with increased behavioral disorders).

!!! REMEMBER: Benzodiazepines are not recommended for use during the day: their sedative effect may increase the disorientation of the patient. However, in liver failure, benzodiazepines are preferred, since the likelihood of developing hepatic coma when using them less than when using other drugs.

Delirium is an acute, transient, usually reversible, fluctuating impairment 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 in 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 during previous hospitalizations. Delirium also often occurs in patients who are at home under the patronage of medical staff. If delirium develops in young people, it is usually the result of drugs or a manifestation of some systemic life-threatening condition.

The DSM-IV defines delirium as “a disorder of consciousness and alteration of cognitive processes that develops over short span time” (American Psychiatric Association, DSM-IV). Delirium is characterized by mild distractibility of patients, impaired concentration, memory disorder, disorientation, and speech impairment. These cognitive impairments can be difficult to assess due to the inability of patients to concentrate and rapid fluctuations in symptoms. Associated symptoms include affective disorders, psychomotor agitation or lethargy, perceptual disturbances 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. Perceptual disturbances are especially often represented by visual hallucinations and illusions, less often they are auditory, tactile or olfactory in nature. Illusions and hallucinations often disturb patients and are usually described by them as sketchy, vague, dreamlike or nightmarish images. Confusion may be accompanied by behavioral manifestations such as pulling systems for 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 disturb other patients or medical staff. Since delirium carries with it an increased risk serious complications and death, it is difficult to overestimate the importance of timely recognition and adequate precisely "silent" delirium. On the other hand, in violent patients, treatment may be limited to suppression of excitation with the help of pharmacological agents or mechanical fixation of the patient, without an appropriate examination that can establish the cause of delirium.

The cause of delirium cannot be accurately determined from the level of activity. The level of activity of the patient during one episode may vary or not fall into any of these categories. Nevertheless, hyperactivity is more often observed with intoxication with anticholinergics, alcohol withdrawal syndrome, thyrotoxicosis, while hypoactivity is more characteristic of 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 the level of consciousness. Delirium is also divided into acute and chronic, cortical and subcortical, anterior and posterior cortical, right and left cortical, psychotic and non-psychotic. BDSM-IV delirium is classified by etiology.

Significance of the problem of delirium

Delirium is actual problem health care, as this very common syndrome can cause serious complications and death. Patients with delirium stay longer in the hospital and are more often transferred to institutions for psychochronics. 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 clouded consciousness combined with confusion, disorientation, possibly delusions, vivid hallucinations or illusions. This state can have many organic causes. At the same time, it is this state of mind that is the basis of protection for medical reasons, and not what caused it. Committing a crime in a state of organic delirium is an extremely rare case. The decision of the court to refer such a criminal to the 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 for lack of intent, or to ask for a hospitalization warrant (or some form of treatment) on grounds of mental illness, or to plead (in very severe cases) insanity under the McNaughten Rules. ).