Delirium Case Study: Mr. J (Sudden Distress)

Mr. J., an older gentleman, was brought to the hospital emergency room. He didn’t know his own name, and at times he didn’t seem to recognize his daughter, who was with him. Mr. J. appeared confused, disoriented, and a little agitated. He had difficulty speaking clearly and could not focus his attention to answer even the most basic questions. Mr. J.’s daughter reported that he had begun acting this way the night before, had been awake most of the time since then, was frightened, and seemed even more confused today. She told the nurse that this behavior was not normal for him and she was worried that he was becoming “senile.” She mentioned that his doctor had just changed his hypertension medication and wondered whether the new medication could be causing her father’s distress. Mr. J. was ultimately diagnosed as having substance-induced delirium (a reaction to his new medication); once the medication was stopped, he improved significantly over the course of the next 2 days.

Diagnosis

The disorder known as delirium is characterized by impaired consciousness and cognition during the course of several hours or days. 

Clinical Description and Statistics 

People with delirium appear confused, disoriented, and out of touch with their surroundings. They cannot focus and sustain their attention on even the simplest tasks. There are marked impairments in memory and language (Meagher & Trzapacz, 2012). Mr. J. had trouble speaking; he was not only confused but also couldn’t remember basic facts, such as his own name. As you saw, the symptoms of delirium do not come on gradually but develop over hours or a few days, and they can vary over the course of a day. 

Delirium is estimated to be present in approximately 20% of older adults who are admitted into acute care facilities such as emergency rooms (Meagher & Trzapacz, 2012). It is most prevalent among older adults, people undergoing medical procedures, cancer patients, and people with acquired immune deficiency syndrome (AIDS). Delirium subsides relatively quickly. Once thought to be only a temporary problem, more recent work indicates that the effects of delirium may be more lasting (Cole, Ciampi, Belzile, & Zhong, 2009). Some individuals continue to have problems on and off; some even lapse into a coma and may die. Many medical conditions that impair brain function have been linked to delirium, including intoxication by drugs and poisons; withdrawal from drugs such as alcohol and sedative, hypnotic, and anxiolytic drugs; infections; head injury; and various other types of brain trauma (Meagher & Trzapacz, 2012).

Causes 

DSM-5 recognizes several causes of delirium among its sub-types. The diagnosis received by Mr. J.—substance-induced delirium—, as well as delirium not otherwise specified, including disruptions in the person’s ability to direct, focus, sustain and shift attention. Delirium may be experienced by children who have high fevers or who are taking certain medications (Smeets et al., 2010). However, that delirium can be brought on by the improper use of medication is a particular problem for older adults, because they tend to use prescription medications more than any other age group. The risk of problems among the elderly is increased further because they tend to eliminate drugs from their systems less efficiently than younger individuals. It is not surprising, then, that adverse drug reactions resulting in hospitalization are almost 6 times higher among elderly people than in other age groups (Olivier et al., 2009). And it is believed that delirium is responsible for many of the falls that cause debilitating hip fractures in the elderly (Stenvall et al., 2006). Although there has been some improvement in the use of medication among older adults with physicians using more care with drug dosages and the use of multiple drugs, improper use continues to produce serious side effects, including symptoms of delirium (Olivier et al., 2009). Because possible combinations of illnesses and medications are so numerous, determining the cause of delirium is extremely difficult (Solai, 2009).

Delirium often occurs during the course of dementia; as many as 50% of people with dementia suffer at least one episode of delirium (Kwok, Lee, Lam, & Woo, 2008). Because many of the primary medical conditions can be treated, delirium is often reversed within a relatively short time. Yet, in about a quarter of cases, delirium can be a sign of the end of life (Wise, Hilty, & Cerda, 2001). Factors other than medical conditions can trigger delirium. Age itself is an important factor; older adults are more susceptible to developing delirium as a result of mild infections or medication changes (Fearing & Inouye, 2009). Sleep deprivation, immobility, and excessive stress can also cause delirium (Solai, 2009).

Researchers studying the brain functioning of persons with and without delirium are beginning to understand the mechanisms underlying this disorder using fMRI scanning (S.-H. Choi et al., 2012). Although such research is potentially important for efforts to both prevent and treat delirium, there are potential ethical concerns. For example, a person experiencing delirium is not capable of providing informed consent for participating in such research, and therefore someone else (e.g., a spouse or relative) must agree. In addition, fMRI testing can be anxiety-provoking for many people and is possibly very frightening for someone already so disoriented (Gaudreau, 2012).

Treatment 

Delirium brought on by withdrawal from alcohol or other drugs is usually treated with haloperidol or other antipsychotic medications, which help calm the individual. Infections, brain injury, and tumors are given the necessary and appropriate medical intervention, which often then resolves the accompanying delirium. The antipsychotic drugs haloperidol or olanzapine are also prescribed for individuals in acute delirium when the cause is un-known (Meagher & Trzapacz, 2012).

The recommended first line of treatment for a person experiencing delirium is psychosocial intervention. The goal of nonmedical treatment is to reassure the individual to help him or her deal with the agitation, anxiety, and hallucinations of delirium. A person in the hospital may be comforted by familiar personal belongings such as family photographs (Fearing & Inouye, 2009). Also, a patient who is included in all treatment decisions retains a sense of control (Katz, 1993). This type of psychosocial treatment can help the person manage during this disruptive period until the medical causes are identified and addressed (Breitbart & Alici, 2012). Some evidence suggests that this type of support can also delay institutionalization for elderly patients (Rahkonen et al., 2001).

Prevention

Preventive efforts may be most successful in assisting people who are susceptible to delirium. Proper medical care for illnesses and therapeutic drug monitoring can play significant roles in preventing delirium (Breitbart & Alici, 2012). For example, the increased number of older adults involved in managed care and patient counseling on drug use appears to have led to the more appropriate use of prescription drugs among the elderly (U.S. General Accounting Office, 1995).

DSM Disorder Criteria Summary

A. A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment). 

B. The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness and tends to fluctuate in severity during the course of a day. 

C. An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception). 

D. The disturbances in Criteria A and C are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma. 

E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physio- logical consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple etiologies.