Delirium

Introduction belongs to the change of consciousness content, and its pathological basis is the obstacle of the function of the whole cerebral cortex. In the past, the literature also classified or equated ambiguity. In fact, is a type of conscious disorder that is more serious than conscious ambiguity. The characteristics of sputum state are: 1 The level of consciousness is reduced, and there is directional disorder. 2 often have psychomotor excitement. 3 There are hallucinations or illusions, especially in illusion. The clinical features of sputum are characterized by attention deficits, low levels of consciousness, perceptual disorders, and disturbances in the sleep-wake cycle. basic knowledge Probability ratio: Susceptible people: no specific population Mode of infection: non-infectious Complications: disturbance of consciousness

Cause

Metabolic abnormalities (30%):

It is the most common cause of convulsions. Fortunately, the above physical examinations and laboratory tests can screen out most of the acquired metabolic disorders, which can be life-threatening and leave a lasting sequela. In some cases (especially hypoxia and hypoglycemia) must be immediately Consider, also pay attention to dehydration, water and electrolyte disorders, calcium and magnesium disorders, rapid changes in electrolyte levels, and the same as absolute value for the development of sputum, for example, some people can tolerate chronic sodium Level 115mmol/L or less, but if it falls to this level quickly, it can cause convulsions, seizures or central medullary cerebral lysis, and hypoperfusion caused by cardiac output or heart failure is another common cause of convulsions. Also pay attention to the failure of other major organs, such as liver and kidney failure, including the possibility of some uncommon causes; such as undetected portal vein short circuit, acute pancreatitis that releases fatty acids, and sputum caused by endocrine dysfunction Common prominent emotional symptoms, such as hyperthyroidism and Cushing syndrome, caused by toxins, including industrial agents, pollutants, Heavy metals such as lead, mercury, strontium, arsenic, gold, strontium and zinc, others should be noted for congenital metabolic abnormalities such as acute intermittent porphyria. Finally, it is particularly important to pay attention to the lack of thiamine (vitamin B1). Alcoholism and other patients with suspected thiamine deficiency must be given thiamine injection immediately to avoid the induction of Wernicke encephalopathy due to the use of glucose.

Drug poisoning (5%):

It is also the most common cause of sputum, especially in drugs with anticholinergic properties, including many drugs that can be purchased without a doctor's prescription, antihistamines, antidepressants and antipsychotics, anticholinergics. Patients with drug poisoning showed fever, enlarged pupils, dry mouth, flushing and confusion, and other drugs related to sputum, especially in the elderly are sedative sleeping pills, narcotic analgesics and histamine-2 blockers.

In patients with Parkinson's disease, anti-shock palsy can cause convulsions, hallucinations and delusions, corticosteroid psychiatry, refers to the dose of prednisone equivalent to 40mg / d or more, the behavioral effects of corticosteroids often Xin Fast and frivolous onset, and overactive sputum, any drug for intrathecal injection, such as iodine, also tend to induce confusion, drug withdrawal syndrome can be caused by a variety of drugs, including Bituto, other weak tranquilizers, sedative sleeping pills, amphetamine, cocaine and heroin (diacetate), as well as alcohol, tremors began to appear 72 to 96 hours after alcohol withdrawal, severe agitation, tremors, sweating, tachycardia , fever and horror visual illusion.

Infection (10%):

Infection and fever often cause paralysis. The main cause is urinary tract infection, pneumonia and sepsis. The important pathogen of sporadic encephalitis and meningoencephalitis is herpes simplex virus. AIDS patients may have sputum, HIV itself and opportunistic infections. As a disease-causing factor, the risk of infection in immunocompromised patients is the greatest. Any infection suspected should be done in time for urine, sputum, blood and cerebrospinal fluid.

Stroke (10%):

is a non-specific consequence of any acute stroke, but ambiguity after cerebral infarction often disappears within 24 to 48 hours. Persistent sputum can be caused by specific stroke including right middle cerebral artery occlusion and frontal and posterior apical regions, and posterior cerebral artery Occlusion causes bilateral or left occipital region (fusiform) lesions. The latter lesion often involves the right hemisphere, which can progress slowly and cause agitation, visual field changes, even Anton (denying visual loss) syndrome, anterior cerebral artery occlusion or Deafness can also occur after rupture of the anterior communicating aneurysm involving the anterior and posterior cingulates.

Other cerebrovascular diseases include high bilateral carotid stenosis, hypertensive encephalopathy, subarachnoid hemorrhage, and central nervous system vasculitis such as systemic lupus erythematosus, temporal arteritis and Behcet's disease can also occur, migraine patients, especially children There may be sputum, and transient ischemic attack (TLA) must be emphasized, even if the vertebrobasilar insufficiency is insufficient.

Epilepsy (5%):

In three cases, epileptic abnormal EEG activity was associated with delirium.

(1) Attack period: absence of persistent state, complex partial seizure persistence, no convulsions of tonic state or periodic ectopic epileptiform discharge (PLEDs).

(2) After the attack: complex part of the attack or after the onset of tonic-clonic seizures.

(3) Interictal period: including epileptic seizures, manifested as irritability, agitation and emotional symptoms associated with impending seizures.

Other factors (5%):

Usually dementia, Lewy body disease, Parkinson's disease and neuroimaging in patients with brain atrophy and subcortical ischemic changes are particularly prone to paralysis, concussion in brain trauma, brain contusion, intracranial hematoma, etc. can lead to paralysis Moreover, the subdural hematoma of the elderly may have only a slight or no history of head trauma. The tumor with fast growth on the screen and the increased intracranial pressure are particularly prone to paralysis. The paracancerous process produces marginal encephalitis and multifocality. Leukoencephalopathy, acute demyelinating disease, diffuse multifocal lesions, traffic or non-communicating hydrocephalus, etc., can lead to paralysis, transient full-forgetting patients begin to have paralysis, followed by disproportionate anterograde forgetting, Retrograde amnesia improved several hours before onset, and patients with Werncke encephalopathy had paralysis, eye movement, nystagmus, ataxia and often left residual amnesia (Korsakoff psychosis).

Fractures in the elderly often have convulsions, 50% of patients with hip fractures have convulsions, orthopedic patients suspected of having fat embolism should check urine, sputum or cerebrospinal fluid fat, anemia in blood diseases, thrombocytopenia and disseminated intravascular coagulation (DIC) Can lead to paralysis, and finally, heat stroke, electric shock, high temperature, etc. can also be the cause of paralysis.

Pathogenesis:

is a change in the content of consciousness. The pathological basis of sputum is the disorder of the function of the whole cerebral cortex. Any intracranial and extracranial lesions can cause different degrees of disturbance of consciousness as long as they involve any part of the non-specific ascending reticular activation system.

The pathophysiological basis of disturbance of consciousness may be caused by mechanical damage of the brain stem or important parts of the cerebral cortex or by comprehensive damage of the brain metabolic process; metabolic-based disturbance of consciousness may be caused by the transport of energy substrates (hypoxia, ischemia, Hypoglycemia), or a change in the neurophysiological response of the neuronal membrane (drug or alcoholism, epilepsy or acute head trauma).

When you are in a state of paralysis, you can find the psychological quality defects of "attention"; "attention" is the direction and concentration of psychological activities on certain things. Directivity and concentration are the two characteristics of "attention".

There are 4 important qualities of attention, namely:

1 Attention to stability refers to the time that can be sustained on certain things.

2 The scope of attention refers to the number of objects that people can perceive at the same time.

3 Note that the allocation means paying attention to two or more different actions at the same time.

4 Note the transfer refers to the purposeful, timely transfer of attention from one object to another.

The second explanation for sputum is the change of neurotransmitters, especially the cholinergic system. Anticholinergic drugs can induce sputum. The sputum can be reversed by using choline drugs such as physostigmine. Furthermore, cholinergic energy can be reversed. Neurons project to the cortex through the pons and basal forebrain, and cortical neurons respond more to other inputs. Decreased acetylcholine leads to reduced perfusion in the frontal cortex. In addition, hypoglycemia, hypoxemia, and other metabolic changes can vary. Degree of influence on acetylcholine regulation.

Prevention

There is no effective preventive measure for this disease. Early detection and early diagnosis are the key to the prevention and treatment of this disease. Develop good diet and living habits in daily life, control cardiovascular disease, reduce the incidence of stroke, and prevent paralysis. At the same time, it also strengthens the monitoring during neurological medication to prevent the occurrence of drug poisoning and prevent convulsions. For diseases such as encephalitis and epilepsy, which are susceptible to convulsions, treatment should also be strengthened.

Complications Complications

Generally no complications.

Symptoms Common symptoms Anxiety Psychic activity Stagnation Illusion Attention Disorders Emotional hearings Nightmare persecution Delusion melody faint fascination change

Symptoms of convulsions often fluctuate rapidly, even within a few minutes, and there is a tendency to sunk after sunset. The most notable symptom is conscious turbidity with misalignment of time, place, and character. It is difficult to concentrate Frequently occurring daily routines and routine routine activities. Personality and emotional changes are common. Symptoms include irritability, misconduct, timidity, excessive energy or even obvious signs of mental illness, such as delusions, hallucinations (usually visual) Illusion) or paranoia. Some patients show quietness, retreat or apathy, while others show excitement or hyperactivity; the irritability of the body often appears to keep moving around. In a short period of time, the patient can Showing contradictory emotions. Thinking can't be organized, incoherent, often with significant ambiguity, too fast speech, new words, aphasia errors, or disorganized language patterns. Normal sleep and eating patterns usually also occur. Inversion. Some patients will feel dizzy.

Awkward inspection

Laboratory tests include whole blood routine, blood glucose, liver function, renal function, blood ammonia, blood gas analysis, urine analysis, and urine drug screening.

A series of EEGS tracking observations can be seen with the substantial changes in EEGs. The structural destruction and general slowing of brain wave rhythm are the most common changes. The degree of rhythm slowing is related to the degree of sputum, and the activity of sputum is low and excessive activity. Two subtypes with similar EEG slowdown; however, low voltage fast activity predominance often occurs in sedatives and alcohol withdrawal patients.

Intracranial causes cause other EEG changes, including focal slow waves, asymmetric activity and paroxysmal release (spine, spike, spine-slow wave synthesis), periodic integrated waves such as three-phase waves and cycles Periodic lateralizing epileptiform discharges (PLEDs) contribute to the diagnosis of sputum caused by focal brain injury such as liver failure, encephalitis, cerebral infarction and cerebral hemorrhage.

In conclusion, EEGs are valuable for the identification of paralysis caused by intracranial causes, for the evaluation of deafness in patients with dementia, and for the identification of delirium and schizophrenia and other primary psychosis.

The evoked potential shows prolonged latency, but non-specific. Lumbar puncture is only considered when the cause is unknown. If the brain is suspected of having focal brain disease, space-occupying lesions or increased intracranial pressure, the brain should be done before lumbar puncture. Department of CT or MRI, lumbar puncture with meningitis signs can help to diagnose the cause.

Other auxiliary examinations include chest radiographs, electrocardiograms, etc.

Diagnostic diagnosis

diagnosis

It is divided into two steps. The first step is to identify whether it is paralyzed. It needs to be completed by medical history, bedside mental condition examination, especially for attention check and review of the diagnostic criteria. The second step is to identify from a large number of possible diagnoses. Causes the cause of paralysis.

The clinical criteria for sputum diagnosis vary widely, and the commonly used mental status scales and tests may not help distinguish sputum from dementia and other cognitive impairments. Due to variability in diagnosis, specific scales and criteria have been developed. Come for a diagnosis.

(1) The diagnostic criteria for the classification of ICD-10 mental and behavioral disorders are as follows:

1 This is a non-specific syndrome of the cause, characterized by simultaneous conscious, attention, perception, thinking, memory, psychomotor behavior, mood and dysfunction of the sleep-wake cycle.

2 can occur at any age, but more common in the 60s and older.

3 The state is short-lived and the severity is fluctuating. Most patients recover within 4 weeks or less, but it is not uncommon for volatility to last for 6 months, especially in chronic liver disease, cancer or subacute bacteria. The paralysis that occurs on the basis of endocarditis.

4 Sometimes people distinguish between sputum and acute and subacute. The clinical significance of this distinction is very small. It should be regarded as a single syndrome with mild variability, ranging from mild to very severe and severe.

5 status can be secondary to dementia or evolve into dementia.

(2) Diagnostic points: The patient can be diagnosed with the following symptoms either lightly or severely.

1 Consciousness and attentional damage: from turbidity to coma, attention to pointing, concentration, persistence and transfer ability are reduced.

2 The overall disorder of cognitive function: perceptual distortion, illusion and hallucination - mostly illusion; abstract thinking and understanding ability damage, may be accompanied by short-lived delusions; but typical people are often accompanied by a certain degree of speech incoherence; Memories and near memory are impaired, but far-memory is relatively intact, time-oriented obstacles, and more serious patients may also have disorientation of locations and people.

3 Mental disorders: activity is reduced or excessive, and unpredictably shifts from one extreme to the other, the reaction time increases, the flow accelerates or slows, and the startle response increases.

4 sleep-wake cycle disorder: insomnia, severe sleeplessness or sleep-wake cycle reversed; drowsiness during sleep; nighttime symptoms worsen; nightmares or nightmares, the content can continue as an illusion until after awakening.

5 emotional disorders: such as depression, anxiety or fear, irritability, euphoria, apathy or surprise confusion.

Differential diagnosis

The main point of differential diagnosis is to conceptually distinguish from mildly conscious turbidity, subacute confusional state and dream-state.

can be defined as a moderate or severe conscious turbidity, and at least one of the following four manifests itself:

1 illusion, hallucinations and other perceptual disorders.

2 speech is incoherent.

3 Mental exercise is uneasy, behavior is disintegrated, and movement is habitual or goalless.

4 short and fragmentary delusions.

On the contrary, the consciousness disorder that none of the above four is is the narrow sense of turbidity.

Subacute confusional state: refers to moderately conscious turbidity that lasts for a few days or more, and its prominent manifestation is the ability to damage complex things. For example, patients can speak long needles and short needles. What is the number (usually checked with a special hard-paper clock face), but there is no time, and as usual, the language is incoherent.

Dream-state: It is also a kind of consciousness disorder that is similar to but different from . When the patient's experience is scattered and unconnected, what is experienced in the dream state is a relatively complete situation. The patient is actually involved. Because of the relative completeness and storytelling of the dream experience, most of the patients can recall, and the experience of the paralyzed patient is completely forgotten.

Because clinical manifestations rarely provide clues to the cause of the disease, differential diagnosis relies mainly on a comprehensive medical history, physical examination and laboratory tests.

1. Differential diagnosis of the cause: almost any serious medical or surgical disease can cause paralysis. The best way to identify is to track all available diagnostic clues. About half of the elderly patients have more than one pathogenic factor. The most common causes of the elderly are metabolic disorders, infections, strokes and drugs, especially anticholinergics and sleeping pills. The most common factors among young people are drug abuse and alcohol withdrawal.

2. Special pathological differential diagnosis: must be distinguished from dementia, Wernicke aphasia and psychosis. The cognitive scale for dementia screening is not reliable for identifying dementia and phlegm. The main distinguishing feature of dementia is long course and lack of prominent fluctuations. Sexual attention and perceptual defects, chronic obsessive state for 6 months or longer is a type of dementia, chronic sputum patients tend to gradually enter a state of drowsiness, the disease rarely fluctuates during the day, the perceptual disorder is rare, - The night cycle is also rarely disrupted. In addition, sputum and dementia often overlap, because paralyzed patients develop high susceptibility to add dementia, and dementia patients should be considered for sudden deterioration.

Language detection can distinguish Wernicke aphasia and slang language. Aphasia patients have different types of idioms, including new language syndrome, and relatively retain the understanding of body axis commands (such as tongue extension, closed eyes), the patient's writing content is empty and wrong. Written, unlike the aforementioned mechanical and technical writing disorders of paralyzed patients.

Psychiatric diseases that can be mistaken for schizophrenia, depression, mania, autism, attention deficit and Ganser syndrome, in general, psychotic patients have no volatility, attention deficit and other defects, schizophrenia patients The speech disorder is prominent, the theme is bizarre, the hallucinations are mostly persecutive voices and rarely horrific visual images. The delusions are systematic and related to the individual. On the contrary, the hallucinations are often visual, imaginary and short. Acute sedative depression and irritability can be mistaken for convulsions. Finally, people who are over 40 years old without a history of mental illness may be caused by sputum. This is a general principle.

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