Delirium: causes and treatment

Brief overview

  • Description: Complex of different mental and physical symptoms, which are all physically (organically) caused (“organic psychosyndrome”). Delirium (delirium) occurs especially often in elderly patients. Men are more often affected than women because they are more prone to alcohol abuse (potential trigger of delirium).
  • Causes: febrile infections, disturbances of the water and electrolyte balance, diseases of the central nervous system (Parkinson’s disease, epilepsy, dementia, meningitis, etc.), alcohol and other drugs, alcohol withdrawal (delirium tremens), metabolic disorders (such as diabetes mellitus), tumors, operations, certain drugs.
  • Treatment: drug relief of delirium symptoms (with neuroleptics, clomethiazole, etc.); if possible, also treatment of the cause of delirium

Delirium is also referred to as an organic psychosyndrome. This term already indicates that both mental and organic components are involved here. In fact, delirium is not a single symptom, but rather an entire symptom complex. Delirium has many of these symptoms in common with mental illnesses, but the respective causes are always physical (organic).

Delirium: symptoms

  • Impaired consciousness and perception, often with impaired memory and loss of orientation. Thinking disorders with cognitive impairment are also included.
  • Psychomotor agitation with a strong urge to move and occasional skidding movements (jactations). Frequent bed-riddenness.
  • exaggerated cheerfulness and/or unfounded anxiety (affective disorders).
  • sleep disturbances
  • mild irritability and states of agitation

In addition to these predominantly psychological symptoms, physical signs of illness usually occur during delirium. These are caused by the involuntary nervous system and are called neurovegetative symptoms:

  • fever up to 38.5 °C
  • increased blood pressure and accelerated pulse
  • profuse sweating (hyperhidrosis)
  • sometimes excessively rapid and deep breathing (hyperventilation)
  • trembling, also called tremor (especially strong in delirium tremens)

Often, the symptoms last only hours or days before they recede and eventually disappear. Without treatment, however, delirium can result in serious cardiovascular and respiratory complications that can lead to death.

Two types of delirium

Medical professionals distinguish between two types of delirium:

  • In contrast, hyporeactive delirium is characterized by a general slowing down – the affected persons appear very calm, sometimes even apathetic.

These two variants need not be present in isolation, but may alternate at unpredictable temporal intervals.

Delirium: Causes and possible disorders

In simple terms, the trigger for delirium symptoms is an imbalance of certain messenger substances (neurotransmitters) of the central nervous system (CNS). These messengers are important for signal transmission between nerve cells (neurons). There are several possible explanations as to why the balance of neurotransmitters is out of whack in those affected and why, for example, too strong signals are sent:

According to the inflammation hypothesis, molecules (so-called cytokines) produced in the course of major inflammations can also disrupt the release of neurotransmitters and thus contribute to delirium. Particularly in the case of systemic inflammation – for example in the form of major infections – there is a certain risk here.

Finally, stress also plays a role. It namely ensures the release of stress hormones (noradrenaline, glucocorticoids), which can have effects on the CNS.

  • CNS diseases: e.g. Parkinson’s disease, epilepsy, meningitis, migraine, traumatic brain injury, cerebral hemorrhage, etc. Delirium also often occurs in the setting of dementia.
  • Tumor diseases: Especially in the dying phase, delirium is a common symptom in cancer patients.
  • Disturbances of the water and electrolyte balance: Possible causes are insufficient fluid intake (especially in elderly people) or the intake of certain medications.
  • Infections and fever
  • Surgical procedures under anesthesia: In the recovery phase after operations, some patients experience delirium (transit syndrome).
  • Certain medications, especially those that have an effect on neurotransmitters such as so-called anticholinergic substances (e.g., drugs for incontinence, Parkinson’s drugs, drugs for nausea and vomiting).
  • Drugs of all kinds, including alcohol
  • Oxygen deficiency (hypoxia)

Delirium tremens (withdrawal delirium)

As with other forms of delirium, delirium tremens is also caused by an imbalance of certain transmitter systems in the CNS. In principle, all the symptoms mentioned above can also occur here, with increased hallucinations:

  • scenic-optical and tactile hallucinations (example: worms, beetles or white mice running over one’s own skin)
  • less frequently: auditory sensory delusions, such as imagined marching music or noises
  • paranoia and other delusions

In addition, in delirium tremens, the eponymous tremor is naturally in the foreground. However, the strong tremor is not always present.

Delirium: When should you see a doctor?

Delirium: What does the doctor do?

In most cases, the doctor can already diagnose “delirium” based on the patient’s symptoms. The severity of the delirium can then be determined with the help of certain test procedures (CAM).

This makes it all the more important to carefully record the patient’s medical history (anamnesis): What are the pre-existing conditions? Is there any alcohol abuse? What is the patient’s life situation? These and other questions are important for the diagnosis of delirium. Here, the statements of the relatives are particularly important, as the affected persons are usually unable to communicate.

  • Electrocardiography (ECG), in order to be able to exclude disturbances of the heart function
  • Heart ultrasound (echocardiography)
  • Measurement of certain laboratory values (electrolytes, kidney function values, inflammation parameters, etc.)
  • cerebrospinal fluid examination (CSF puncture)
  • Electroencephalography (EEG) to measure brain waves
  • Computer tomography (CT) and magnetic resonance imaging (MRI)

Therapy of delirium

  • Neuroleptics (antipsychotics) such as haloperidol: These are administered primarily for hyperactive forms of delirium.
  • Clomethiazole: This is the most commonly used agent in delirium tremens.
  • Benzodiazepines (sleeping pills and sedatives): These are used primarily in withdrawal delirium, but are also used for other forms of delirium.

In addition, the cause of the delirium is treated or eliminated if possible. If, for example, disturbances in the water and electrolyte balance are the trigger, these must be remedied (for example, by means of infusions).

Delirium: What you can do yourself

In addition to medication, other treatment concepts also play an important role in the treatment of delirium. Above all, the patient’s relatives can help. Initially, this is already done by their mere presence:

There are also studies that show that relaxing music and smells can help patients. Those who take these aspects to heart can support the healing process in delirium.