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Close concepts: acute organic brain syndrome, acute brain insufficiency, feverish delirium, acute confusion, acute pathopsyhosis, toxic confusion, toxic delirious reaction, reversible weak-mindedness, metabolic encephalopathy, toxic encephalopathy
Lipowski means the passing mental disorder reflecting acute insufficiency of a brain owing to diffusion disturbance of a metabolism by a delirium. This definition is based on data of Engel and Romano which showed that the delirium is manifestation of metabolic insufficiency of a brain. Proceeding from definition, a delirium — the physiological decompensation of functions of a brain similar to a syndrome of a heart, renal or liver failure.
Discussing etymology of the word "delirium", Lipowski tracked its use since the time of Hippocrates. This term was entered into medical literature approximately in 1 century to and. aa. The word "delirium" comes from the Latin verb Delirare which means literally "to fly into a rage". However from the very beginning the term "delirium" is used as a synonym of madness, madness, confusion of consciousness. Besides, it is used as the description of the passing mental syndrome accompanying somatopathies, in particular episodes of high fever. In psychiatric literature the delirium is called an acute organic brain syndrome; in neurologic literature — diffusion or toxic encephalopathy; in all-medical literature it is applied to the description of delirium tremens or feverish reactions.
Engel and Romano pay attention to funny inconsistency of doctors: they are, as a rule, convinced of the organic nature of mental diseases, but nevertheless usually are not interested in a delirium, and meanwhile it — the only mental disease which is strongly known that he is called by disturbance of a metabolism of a brain. Because of inconsistency of terminology, methodological approaches and the prejudiced relation of doctors to psychiatry doctors of other specialties very often neglect this important syndrome.
The delirium can be caused in experiment by very many chemicals, for example alcohol, barbiturates, the general anesthetics, and also a hypoxia, sleep deprivation and a withdrawal of drugs. Besides, quite often the delirium complicates somatopathies, for example a renal failure, a liver failure, a hyperthyroidism, a hyperglycemia, and also the postoperative period. However the pathophysiological mechanisms which are the cornerstone of development of a delirium are unknown so far. The brain represents set of neurons which are very sensitive to changes of the physiological environment. Changes rn, a blood-groove, concentration in blood of glucose, metabolic products, for example ammonia, can significantly influence metabolic activity of a brain.
Clinically the delirium syndrome always includes the following types of disturbances of mental functions:
1. Inability to perceive and acquire the new information arriving from the outside. This disturbance is usually shown by disorientation in time and space, disturbances of a short-term memory and reproduction of information, a wrong assessment of the new facts and persons as acquaintances, sketchy or not logical thinking. At the same time the patient often makes impression of the person with the confused consciousness if this term appears in the report of the sister on duty, it is necessary to take into account the diagnosis of a delirium always.
2. Disturbances of attention. At the patient take place of various extent of disturbance of attention (from superexcitability to a stupor). Ability to concentration, movement and constant tension of attention is broken. The patient can easily distract, not react to changes in questions, or just "be switched off" from contact.
3. Sleep disorders. At deliriums there are always sleep disorders. Are characteristic of a delirium the interrupted or fragmentary dream, sleeplessness, a stupor. At patients with a delirium sleeplessness clinically is most often observed, however the recovered patients quite often describe it as a snopodobny state. To the contrary, the slowed-down patients can be in a stupor, making impression of a dream almost throughout the day. The sleep disorders found by nurses at the patient can help to make early the diagnosis of a delirium. Recovery of a normal dream often is the first sign of recovery.
Contrary to functional psychoses which develop gradually for weeks or months during which more or less strange finishing is observed the delirium is characterized by the acute beginning. Also fluctuations between full consciousness and confusion are characteristic of a delirium. At the beginning this state is reversible, but if it in time not to find and not to remove the metabolic cause of a delirium, it can progress up to irreversible disturbances of functions of a brain and death. Depending on an etiology it can proceed from several hours to several months. Stratifications of secondary psychotic symptomatology can be noted. Illusions and hallucinations often occur at patients with a delirium that can lead to the wrong diagnosis of functional psychosis and the subsequent wrong treatment.
Lipowski believes that there are two clinical options of a delirium: hypoactive and hyperactive (on Steinhart — hypoexcitable and hyper excitable types). The mental condition of the patient can correspond to one of these types throughout all illness, or the hypoactive state can be replaced hyperactive and vice versa. The hypoactive type more often remains unnoticed because of the passivity of the patient caused by a semi-struporous state. At the same time usually mental pathology is noticed, only if braking goes deep to a full stupor or block is replaced by a hyperactive state. Patients with hyperactive type of a delirium the medical personnel usually call "plokhoupravlyaemy". Excitement, unsociability and lability of mood are characteristic of a hyperactive state. At patients illusions and hallucinations because of which they can make the diagnosis of psychosis mistakenly are quite often observed. In such situations the wrong and dangerous tactics of treatment is quite often applied: nurses consider themselves is not able to cope with such patient and call the doctor on duty, and the doctor as a symptomatic treatment appoints antipsychotic or sedative drugs. Such tactics usually aggravates a picture of a delirium and distracts attention of doctors from a somatic cause of illness.
Clinical examples. The clinical example illustrating hypoactive option of a delirium is included below:
Patient I., 62 years, mother of three children, with complaints to acute pains in a thorax came to university hospital for establishment of the diagnosis. At receipt bronchitis (possibly virus), moderately expressed infection of urinary tract, moderate obesity and the compensated diabetes form is found in it. For the fifth day of stay in a hospital at the patient drowsiness began to develop and indifference to food appeared. The attending physician caused on consultation of the psychiatrist, assuming existence at the patient of a depressive syndrome. In the analysis of data of a case history it was revealed that hepatic tests are on norm border, and nurses registered increase in duration of a dream and one episode of confusion of consciousness is noted. In conversation with the psychiatrist the patient claimed that she was familiar with him earlier and that he is friend of the family. The patient is disoriented in time and space, fluctuations of attention, frustration of thinking are noted. At further inspection, including an assessment of function of a liver, the acute liver failure was found.
This example is in many respects a typical case of a hypoactive or struporous delirium. Before an aggravation of symptoms at the patient disturbances of consciousness were missed, and further are regarded as a heavy depression. It is necessary to emphasize that in this case the attending physician insisted that the patient has no somatopathy. Only after consultation of the psychiatrist the patient was a doobsledovana and the liver failure was revealed.
The hyperactive option of a delirium illustrates the following supervision:
Sick N., 67 years, the pensioner, came to university hospital for planned operation for benign adenoma of a prostate. Before operation the condition of the patient was good, operation took place successfully. The postoperative period was complicated by the infection which is quickly eliminated with use of antibiotics. However at the same time the patient had a concern and excitement which were regarded as reaction to hospitalization. The patient was written out home where he was looked after by his daughter — the nurse. To the patient amitriptyline (elavil) on 50 mg 4 times a day was appointed. Within 3 months of the patient slept approximately on 2 h during the night, during wakefulness its state was characterized by concern, excitement and the periods of confusion. In 3 months the family doctor directed the patient to consultation to the psychiatrist concerning assumed depressions. At initial psychiatric inspection the dezoriyentirovznnost, fluctuations of attention and illogical associative thinking is found. On EEG generalized delay of a rhythm is revealed. The diagnosis of a delirium is made. At careful somatic inspection of associated diseases it was revealed not. Cancellation of reception of amitriptyline in 14 days led to a complete recovery of health.
In this case the patient with a postoperative delirium was written out unreasonably early. Mental disturbances were aggravated with purpose of amitriptyline as in typical cases the delirium either progresses, or it is quickly enough independently allowed. And at last, despite rather clear signs of a delirium (primary psychiatric symptomatology and characteristic picture EEG), the diagnosis of a mental disease was made mistakenly.
Risk factors of a delirium
At some patients the risk of development of a delirium is increased. Three major factors contributing to development of a delirium are known: advanced age, existence in the anamnesis of injuries of a brain and accustoming to alcohol or drugs. Exposure to delirious states increases the patient with age, and the explanation of this process is not found so far. Frequency of development of a delirium, by data a miscellaneous of authors, very varies. For example, according to Liston, the frequency of development of a delirium in patients of old age in therapeutic and surgical departments makes from 14 to 30%. The causal relationship between the previous injury of a brain and development of a delirium is proved. The delirium often develops at the persons abusing alcohol or drugs and also at a withdrawal that significantly complicates treatment of patients with medicinal dependence or alcoholism. Along with the specified factors some authors give others, for example a state after operation, restriction of touch information, a sleep disorder, a psychological stress, features of the personality. For example, steady persons with the expressed self-checking are probably less subject to a delirium, than ordinary individuals. If to consider set of the specified factors, it is possible to reveal at early stages of a disease sick, subject to development of a delirium.