DELIRIUM (Versione Inglese)

Definition:

Delirium is an acute and transient syndrome characterized by altered consciousness and cognitive functions (attention, orientation, memory), with a sudden onset and fluctuating course during the day.

Epidemiology:

• Common in hospitalized elderly patients (especially >65 years)

• Affects about 10–30% of hospitalized patients, up to 50–70% in intensive care or post-operative units

• Often underdiagnosed

Types of Delirium:

1. Hyperactive: agitation, anxiety, hallucinations, insomnia

2. Hypoactive: apathy, slowing, confusion (harder to recognize)

3. Mixed: alternates between hyperactive and hypoactive symptoms

Pathogenesis:

It involves alterations in cerebral metabolism, neurotransmission (dopamine, acetylcholine), and fluid/electrolyte or inflammatory balance.

• A vulnerable brain (especially in the elderly) reacts abnormally to acute stress (e.g. infections, medications, pain, hospitalization).

Main Causes:

• Infections (e.g. pneumonia, urinary tract infections)

• Dehydration, electrolyte imbalances

• Hypoxia, hypoglycemia, fever

• Medications (benzodiazepines, anticholinergics, opioids)

• Alcohol or substance withdrawal

• Surgical procedures, uncontrolled pain

• Acute neurological diseases (e.g. stroke, head trauma)

• Prolonged immobility

Risk Factors:

• Advanced age

• Dementia or cognitive decline

• Previous episodes of delirium

• Prolonged hospitalization

• Multiple illnesses and polypharmacy

• Visual or hearing impairments

• Sleep disturbances

Diagnosis:

• Clinical observation: sudden confusion, inattention, disorientation, altered speech or behavior

• Assessment tools:

• CAM (Confusion Assessment Method) – most used

• DOS Scale or 4AT

• Lab tests, urine culture, brain CT if needed

Treatment:

Treat underlying cause:

• Correct metabolic imbalances

• Treat infections

• Review and adjust medications

• Ensure proper hydration, oxygenation, pain control

Pharmacological support (only if necessary):

• Low-dose antipsychotics (e.g. haloperidol, quetiapine)

• Avoid benzodiazepines (except in withdrawal delirium)

Nursing Care:

• Continuous monitoring of cognitive and behavioral status

• Quiet, well-lit environment with familiar objects

• Frequent reorientation (remind of time, place, identity)

• Correct sensory support (e.g. glasses, hearing aids)

• Support natural sleep: avoid night-time noise or bright lights

• Early mobilization

• Supervise to prevent falls or injuries

• Involve family members as a calming presence

Advice and Prevention:

• Early identification of at-risk individuals

• Avoid inappropriate use of psychoactive drugs

• Ensure adequate hydration and nutrition

• Effective pain management

• Support the natural sleep-wake cycle

• Avoid unnecessary catheters or IV lines

• Encourage daily movement and cognitive/social stimulation

• Don’t forget to exercise as much as you can