Abstract:
Delirium may be a common cause of psychotic symptoms such as hallucinations, bizarre delusions and thought-disorder, even in conditions such as schizophrenia, mania and depression, where delirium has traditionally been excluded by definition. This situation is a consequence of the insensitivity of current clinical criteria for the diagnosis of delirium, which recognize only the most severe forms of functional brain impairment (including disorientation and clouding of consciousness). Serial electroencephalograms (EEGs) are the most sensitive method for detecting delirium, and until such studies are performed, the true incidence of delirium in psychotic patients will not be known. The suggested causal mechanism of delirium in psychosis is sleep disruption. Sleep is essential for maintenance of memory circuits, which otherwise suffer progressive synaptic weakening due to molecular turnover. When sleep is disrupted, memory circuits deteriorate, and subsequent activation of incompetent circuits can generate psychotic symptoms. Induction of physiologically normal sleep would therefore be expected to produce significant clinical improvement in patients with psychotic symptoms. Furthermore, the ‘anti-delirium’ action of electroconvulsive therapy may account for its effectiveness in alleviating a wide range of psychiatric and neurological pathologies. Charlton BG, Kavanau JL. Delirium and psychotic symptoms–an integrative model. Med Hypotheses. 2002 Jan;58(1):24-7. doi: 10.1054/mehy.2001.1436. PMID: 11863395.
As suggested in the abstract below, ECT, and, perhaps other “psychiatric” medications, such as SSRI’s or “antipsychotics” , or other “tranquilizers [and these drugs are all considered tranquilizers] are helpful in clearing up delirium and different types of insomnia.
It is proposed that electroconvulsive therapy (ECT) is not specifically mood-elevating or anti-depressant but that its effect is as an anti-delirium intervention. I suggest that ECT exerts its primary therapeutic effects by inducing a generalized epileptic seizure which operates on the brain like a deep and restorative sleep that acts rapidly to resolve delirium. Provided that the diagnosis is made using sufficiently sensitive criteria, delirium is here assumed to be a common feature of many so-called ‘functional’ psychoses – frequently occurring as a consequence of sleep deprivation, and leading to symptoms such as hallucinations, bizarre delusions and psychomotor retardation. Testable predictions of this ‘anti-delirium’ theory of ECT action are described. Charlton BG. The ‘anti-delirium’ theory of electroconvulsive therapy action. Med Hypotheses. 1999 Jun;52(6):609-11. doi: 10.1054/mehy.1999.0857. PMID: 10459846.
There is no reason to exclude delirium from severe mental illness, except for the false divide between physical and mental illnesses. We already know that insomnia which is lasting, eventually results in psychosis and/or delirium. Psychosis and/or delirium are just words , but these different words will dictate whether a medical approach or a psychiatric approach will be applied. And the differences between these approaches are immense. The investigation of psychosis is very different from investigation of delirium. This is the reason that we have not progressed in the treatment of psychotic illness such as manic depressive insanity, schizophrenia, and dementia. Psychotic illness such as manic depressive insanity, schizophrenia, and dementia require medical investigations not psychiatric ones.
Interestingly, psychiatrists are much better at detecting patterns of what I suspect to be the mood and behaviour and speech and motor patterns of chronic delrium.
Other specialties tend to miss behavioural delirium altogether, especially if they are of the silent type, where the patient does not vocalize their discomfort or distress to where they use very basic language which is not clear; eg. I feel bad, I am very anxious, etc…
Abstract
Objectives
Missing delirium in the emergency department (ED) has been described as a medical error, yet this diagnosis is frequently unrecognized by emergency physicians. Identifying a subset of patients at high risk for delirium may improve delirium screening compliance by emergency physicians. We sought 1) to determine how often delirium is missed in the ED and how often these missed cases are detected by admitting hospital physicians at the time of admission, 2) to identify delirium risk factors in older ED patients, and 3) to characterize delirium by psychomotor subtypes in the ED setting.
Conclusion
Delirium was a common occurrence in the ED and the vast majority of delirium in the ED was the hypoactive subtype. Emergency physicians missed delirium in 76% of the cases. Delirium that was missed in the ED was nearly always missed by hospital physicians at the time of admission. Using a delirium risk score has the potential to improve delirium screening efficiency in the ED setting.
Keywords: delirium, emergency department, elder, unrecognized, psychomotor, risk factors
Han JH, Zimmerman EE, Cutler N, Schnelle J, Morandi A, Dittus RS, Storrow AB, Ely EW. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. 2009 Mar;16(3):193-200. doi: 10.1111/j.1553-2712.2008.00339.x. Epub 2009 Jan 20. PMID: 19154565; PMCID: PMC5015887.
In the above paper, delirium was missed 76% of the time in the elderly, a patient group known by doctors to have an increased risk for delirium.
The younger patients with hypo-active delirium [unless visibly close to dropping dead and even then] will most likely not be diagnosed as delirious but the hypoactive mood and behaviour will warrant a referral to psychiatry, where delirium will still be missed or rather it will be seen as depression or anxiety as mood disturbance not as a part and parcel of delirium, and the same will be true of psychosis. Psychosis- the very definition of delirium, in many ways, will not be recognized as delirium because the delirium has become chronic because some organic problem is maintaining the delirium and we do not yet know what the organic problem or problems are.
still writing, still editing, ……….
The main problem is the inability of most doctors [psychiatrists, neurologists, primary care] to go beyond recognizing mood and behaviour patterns [which, let’s face it , is not that hard to do if you have seen people with mood disorders or with psychotic/thinking disorders. It is clear that these patients are not “all right” and need help and may even need physical care [food, shelter, etc..] while they are unable to take care of themselves .
Psychiatrists are pretty good at noting “mental” disorders.
In some ways, psychiatrists are better than other doctors at recognizing “altered mental status and delirium which has become chronic.
………to be continued…..
Of Sound Mind 