Delirium: causes & symptoms of delirium

The term delirium is often associated with the signs of alcohol withdrawal. Confusion occurs particularly after operations, known as delirium or (outdated) transit syndrome. But what exactly happens when delirium occurs, how long does it last, and what symptoms can occur? You can find answers to these and other questions in the following article.

 

Delirium is a sudden, severe state of confusion. This becomes noticeable through impaired consciousness, disorientation and impaired thinking. Delirium is considered a psychosis that is caused by physical causes (organic psychosis). Other names for delirium are delirium, transit syndrome, delirious syndrome or acute confusional state.

Acute delirium is an emergency that can be life-threatening and requires immediate medical attention.

 

Delirium: diverse symptoms

The symptoms of delirium are very diverse, which is why, in some cases, the diagnosis is delayed or not made at all – because the signs are often not easy to recognize, even for medically trained staff. The symptoms can be divided into different areas.

• Disorientation: Those affected often no longer know where or why they are there. The sense of time is also lost.
• Decreased attention: Attention may be disturbed, causing patients to appear unfocused and distracted. During the conversation, it is also noticeable that the topics change abruptly, and the train of thought breaks off.
• Mental and physical impairments (psychomotor disorders): Those affected are mentally and physically very restless, jumpy or even short-tempered. On the other hand, sluggishness (lethargy) and apathy (apathy) can also be observed.
• Disturbed sleep-wake rhythm: Sleep disorders occur when those affected are awake and active at night and sleep during the day.
• Disturbances of perception and thinking: Illusions (hallucinations) occur. Things are seen or heard that do not exist, for example:
  • The nursing staff in the hospital only pretend to want to help.
  • Close relatives have died.
  • Dangerous animals nearby that want to attack
  • Deviant explanations for events in the area are sought.

It is characteristic that the signs of delirium appear suddenly and do not develop gradually. In addition, they can change it on concise notice. Severe confusion and other disturbances of consciousness can alternate with precise moments in which those affected appear mentally fit.

Hypoactive and hyperactive delirium

Based on the symptoms, two types of delirium are distinguished:

• Hypoactive delirium:  This is characterized by severely reduced activity; the patient is barely or not at all responsive. People with hypoactive delirium appear apathetic, and attention and motor skills are slowed.
• Hyperactive delirium:  This rarer type is characterized by excessive activity and restlessness; the patient may become aggressive. These people appear agitated and may show mood swings and psychotic symptoms.

In most cases, there is a mixture of the two types, so the different symptoms occur alternately.

 

Risk factors for delirium: Who is at risk?

Some groups of people are at greater risk of developing delirium. Risk factors include:

• existing dementia
• older age and living situation in a nursing home
• Taking certain medications
• Liver disease, Parkinson’s disease or stroke
• Visual and hearing impairments
• Alcohol abuse and drug use
• arterial hypertension (high blood pressure)
• Diabetes mellitus
• Malnutrition or dehydration (lack of fluids)
• Depression or loneliness

Delirium can result if these factors coincide with specific triggers such as surgery or an infection. The risk factors mentioned can represent such a trigger, such as dehydration or taking medication. The more predisposed a person is, the more likely delirium will occur, even with less severe triggers.

Für Ärzte*Ärztinnen ist es daher wichtig, beispielsweise vor einer OP über das Vorliegen möglicher Risikofaktoren informiert zu sein, denn mit entsprechenden Maßnahmen zur Prävention (beispielsweise den Verzicht auf bestimmte Arzneimittel) kann versucht werden, die Wahrscheinlichkeit eines Delirs zu reduzieren.

Was kann ein Delir auslösen?

Die genauen Ursachen für die Entstehung eines Delirs sind noch nicht geklärt. In der Regel handelt es sich um ein Zusammenspiel verschiedener Faktoren, die in einer Ausnahmesituation auf den Menschen einwirken.

Eine solche Ausnahmesituation kann zum Beispiel sein:

• eine größere Operation
• ein Krankenhausaufenthalt, insbesondere auf der Intensivstation
• eine schwere Infektion mit hohem Fieber, auch COVID-19
• der Entzug von Alkohol oder Medikamenten oder aber die Gabe bestimmter Arzneimittel
• ein künstliches Koma
• Nahrungsmangel oder zu wenig Flüssigkeit

In einer solchen Situation leidet der Körper unter Stress, der zum Beispiel durch Narkosemittel, Schmerzen, Verletzungen oder Entzündungen ausgelöst werden kann. Infolgedessen gerät die Signalübertragung zwischen den Nervenzellen im Gehirn aus dem Gleichgewicht. Es werden teilweise zu starke oder zu schwache Signale zwischen den Nervenzellen gesendet. Ältere Menschen scheinen besonders anfällig für diese Funktionsstörung des Gehirns zu sein.

Delirium: Formen der akuten Verwirrtheit

Man unterscheidet je nach Auslöser verschiedene Formen des Delirs, beispielsweise die folgenden:

Das postoperative Delir tritt meist innerhalb von fünf Tagen nach einer Narkose im Zuge einer Operation (OP) auf. Es stellt eine der häufigsten Komplikation nach einer OP dar – insbesondere im Alter von mehr als 65 Jahren oder bei Demenzkranken. Dabei kann es sowohl nach einer Vollnarkose als auch nach einer örtlichen Betäubung auftreten. Das Risiko für ein postoperatives Delir ist nach großen operativen Eingriffen mit einer langen Narkose, wie bei einer Herz-OP oder einem Hüftgelenksersatz, besonders hoch.

Da man in der Vergangenheit davon ausging, dass es sich beim Delir nach einer OP um einen vorübergehenden Zustand handelt, wurde es früher auch als Durchgangssyndrom bezeichnet. Heutzutage weiß man, dass nach einem Delir bei circa 25 Prozent der Betroffenen Wahrnehmungsstörungen dauerhaft auftreten können. Die Verwendung der Begriffe “Durchgangssyndrom” und “Übergangssyndrom” wird daher von Fachleuten nicht mehr empfohlen. Umgangssprachlich werden die Bezeichnungen jedoch weiterhin häufig genutzt.

Bei sehr hohem und langanhaltendem Fieber kann es zu einem Fieberdelir kommen. Dabei ist die Wahrnehmung der Betroffenen gestört, es kann zu Ängsten und Unruhe oder auch zu großer Teilnahmslosigkeit kommen.

Bei bestehender Alkoholabhängigkeit kann durch Alkoholentzug ein Delir hervorgerufen werden. Ein anderer Name für das Alkoholentzugsdelir ist Delirium tremens.

 

Wie kann es zu einem postoperativen Delir kommen?

Die Situation nach einer OP und ein möglicher Aufenthalt auf der Intensivstation bedeuten für Patient*innen enormen Stress. Abgesehen von den körperlichen Leiden kommt die psychische Belastung durch Angst und Ungewissheit hinzu.

Zu den körperlichen Auslösern eines postoperativen Delirs gehören:

• Narkosemittel während der OP
• der Eingriff selbst, da es zu einer Verletzung und einer nachfolgenden Entzündungsreaktion kommt
• Medikamente im Anschluss an die OP

Auch eine schwere Erkrankung ohne OP, die einen Aufenthalt auf der Intensivstation erforderlich macht, kann zum Delir führen.

Zudem stehen bestimmte Medikamente im Verdacht, das Gehirn so zu belasten, dass ein akuter Verwirrtheitszustand entsteht. Ein Delir auslösende Medikamente können beispielsweise Sedativa sein. Sedativa sind Medikamente mit beruhigender und dämpfender Wirkung. Hierzu gehören Wirkstoffe wie Benzodiazepine, Barbiturate, Propofol und Ketamin. Dies sind Beruhigungsmittel, die Intensivpatient*innen zur Dämpfung von Angst und Unruhezuständen verabreicht werden. Denn bei ruhigen Personen können diagnostische und therapeutische Maßnahmen, wie eine künstliche Beatmung, leichter durchgeführt werden.

Deliver und Demenz

Delir und Demenz können manchmal nur schwer voneinander getrennt werden, denn die Anzeichen sind oft ähnlich. Wie wichtigsten Unterscheidungsmerkmale sind folgende:

Delirium can also occur in dementia. Delirium can occur, for example, when people with dementia forget to drink, and there is a lack of fluid in the body. Diarrhoea or taking certain medications can also lead to delirium in older people with dementia. Delirium in dementia is particularly critical because it often goes unrecognized. This increases the risk of far-reaching consequences for those affected, such as a significant deterioration in short-term memory.

Delirium in the dying phase

Delirium develops in more than two-thirds of people in the dying phase, i.e. in the last three to seven days before death. This often remains undetected, especially when it comes to those affected who also have dementia. It is essential in this situation to reduce stress and anxiety and to relieve any pain that may be present. From a medical point of view, this includes the administration of appropriate medication, normalizing the fluid balance, and improving the oxygen supply.

 

How common is delirium?

In Germany, in particular, patients who have to undergo treatment in hospital develop delirium:

• Approximately three to four out of ten people (30 to 40 per cent) who are hospitalized as inpatients
• Up to three out of 10 people (30 per cent) of those who are in intensive care, with ventilation, it is even 8 out of 10 people (80 per cent)

However, the information on the frequency in different studies differs significantly, which can be attributed primarily to methodological differences.

How long does delirium last?

Delirium is a temporary condition. The duration of acute confusion ranges from a few hours to many days but can also extend over several weeks. In most cases, the signs of delirium appear very quickly at the beginning. The further course can be characterized by various phases that alternate quickly: those affected appear entirely normal, and the next moment, they are disoriented and cannot distinguish between reality and fantasy.

In some people, delirium affects brain function over a long period. Long-term effects such as poor concentration and forgetfulness can occur. However, most sufferers overcome the delirium and make a full recovery.

What makes delirium so dangerous?

Even if temporary confusion may not appear life-threatening at first glance, delirium is quite dangerous.

The most significant risk is that delirious people endanger themselves. For example, they tear out catheters or breathing tubes or injure themselves when they fall because they want to get out of bed and run away on their own. Many patients also refuse the necessary treatment or rehabilitation measures because, for example, they feel threatened by the hospital staff as a result of their hallucinations. This can lead to life-threatening complications or delayed recovery.

But non-life-threatening consequences such as the need for care or dementia are also possible.

 

How do you treat delirium?

Treatment for delirium depends on the cause. Therefore, it is essential first to find the cause of the acute confusion. If, for example, a bacterial infection is the cause, it can be treated with antibiotics . If the cause is treated, the delirium can improve quickly. Drugs such as neuroleptics or tranquillizers are often used to relieve symptoms. For example, haloperidol, risperidone or quetiapine are used.

In addition to drugs, non-drug measures are also crucial in therapy. These include, for example:

• Create a calm atmosphere that conveys security and stability
• Relatives who get involved and create closeness to those affected
• Start mobilizing early after an operation to strengthen muscles and circulation.
• Encourage mental activity, such as games or puzzles.
• Provide orientation, for example, hang up a clock or a calendar in a visible position and encourage the person to use glasses and hearing aids if necessary

Since delirium is a clinical picture that can have many different causes, it is often difficult to treat. The most crucial goal of therapy is to bring those affected back to everyday life in small steps.

Therapy for delirium: what can relatives do?

An acute state of confusion is a frightening situation not only for those affected but also for their relatives. Relatives should, therefore, first realize that, in most cases, delirium passes without consequences. This way, you can deal with it better.

It is helpful to heal delirious people if familiar people are present, look after them, and talk to them. This is especially important if you are staying in the hospital. Relatives can do the following:

1. Spend as much time as possible with the affected person. If necessary, make arrangements within the family so that you can alternate visits. At the same time, this also relieves the burden on individual family members.
2. Try to remain calm and level-headed, even if the person is restless and confused. Explain to her repeatedly where she is and why the stay in the hospital is necessary.
3. Talk to the person a lot so they can hear your voice. If you don’t know what to discuss, read from a book or look at photos together and say something about it.
4. Hold the person’s hand to show closeness, reassure them, and reassure them.
5. Bring things from home. You can create a familiar atmosphere with small things such as pictures, pillows or a cosy blanket.
6. Keep a diary where you write down what happens daily. This can later help to close gaps in memory and sort memories.

These measures can lead to a faster resolution of the symptoms and support the healing process in delirium.