The concept of delirium

Lindesay, James Dementia and Geriatric Cognitive Disorders; Sep/Oct 1999; 10, 5; ProQuest Health & Medical Complete pg. 310

and Ge riatric Cognitive Disorders

Dementia

Dement Geriatr Cogn Disord 1999;10:310-314

The Concept of Delirium

James Lindesay
Department of Psychiatry, University of Leicester, Leicester General Hospital, Leicester, UK

KeyWords
Delirium Dementia Classification History

na, but often display deplorable looseness in the use of words that arc indispensable for labelling, classifying, and explaining what is obsened and recorded' [1]. The term delirillill first occurs in the writings of Cclsus

Abstract
The concept of delirium has a long and confusing histo ry. This article outlines the development of ideas relating to core features of the syndrome: disturbance of con sciousness, disturbance of cognition, its course and its external causation. The modern concept of delirium, and the diagnostic criteria found in current classifications are based upon a long tradition of clinical observation in younger patients, and their emphasis on positive symp toms and identifiable external causes may not be appli cable to our ageing population.

in the 1st century AD. but the condition to which it refers was clearly well recognised by earlier authors. There arc many descriptions of what we would recognise as delir ium in the Hippocratic writings. particularly in the books of Epidemics. These writers used the term phrenilis to refer to the transient mental disorder that was associated with physical illness. and characterised by restlessness. insomnia and disturbances of mood, perception and \vit'. The ancient authors also recognised !ethargus. with som nolence. inertia and reduced response to stimuli. as a clin ically related disease. It is not clear whether lethargus was synonymous with what we would now describe as a hypoactive delirium. or whether it was merely pretermi nal exhaustion and coma; observations on its bad progno

Delirium was one of the first mental disorders to be described. and the evolution of the concept reflects the many changes in thinking about the nature and aetiology of mental illness that have occurred throughout the histo ry of medicine and psychiatry. Lipowski [1. 2] has studied and described the development of dclirium as a mental disorder, and has remarked on the terminological chaos that has characterised its history from ancient times to the present day. As he says: ,It appears that clinicians by and large excel in observing and describing natural phenome-

sis suggest the latter. The inconsistent and ambiguous application of the term delirium to all or part of the phre nitic and lethargic states by subsequent writers is at the root of much of the terminological confusion noted by Lipowski. Another problem has been its parallel use as a general term to describe derangement and insanity. usual ly of a florid and raving kind. which has encouraged its association with only the more active mental disturbances due to physical illness or intoxication.

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A detailed discussion of the historical dcvelopmcnt of delirium is bcyond the scope of this paper, and the inter ested reader is referred to Lipowski [I, 2]. Instead, a brief historical overview will be given of the development of ideas concerning thosc aspects of the condition currently thought to be core features (see below): disturbance of consciousness, disturbance of cognition, the course of the disorder, and external causation.

and preoccupation with subjccti vc cvcnts distorted by perceptual and affective disturbances [e.g. 8]. This con ccpt survived as an cssential fcature of delirium into DSM-I1I [9]. though it was subsequently dropped because it is so difficult to measure. It was replaced by disturbed attention in DSM-IV [10]. reflecting the conecptualisa tion of delirium as an attcntional disorder. Clouding of consciousness is howeyer retained in the ICD-l 0 diagnos tic critcria for rcscarch [11] for delirium. Delirium as a disorder of lowered consciousness is dis

Disturbance of Consciousness

cussed by Hughlings Jackson [12] in terms of his hierar chical model of the organisation of thc ccntral ncrvous system. Loss of the highest nervous centres leads to both the negative symptoms (disorientation. confusion, im paircd mcmory) due to local loss of function, and to posi tive symptoms (hallucinations, delusions. 'extravagant conduct') due to releasc of activity at lower levels. In the 20th century. thc major advance in this area has been the correlation of elinically observed and measured disturbances in consciousncss and cognitive function with objective measures of brain metabolic function, notably electroencephalography (EEG) [13]. More recently. this experimental approach has led to the hypothesis that dys function of central cholinergic systems is the pathological substrate of disturbed consciousness in delirium [14].

Observations on the disturbances of consciousncss as sociated with delirium relatc to both the sleep-wake cycle, and to thc continuum between alertness and coma. They will be considered separately. Insomnia and troublesome sleep have been notcd as features of delirium from ancient times onward. and the importance of restoring normal function emphasised. as in the Hippocratic aphorism: 'When a delirium or raving is appeased by sleep, it is a good sign.' The usc of medication to encourage this was recommended. although as Barrough [3] noted in thc 16th ccntury. some care was required: 'somnoriferous potions do noe small hurt, and somctime they kill'. From thc 17th century onward, there was much specu lation about the nature of the relationship between delir ium and sleep. and a number of explanatory hypotheses proposed. Some authors considered delirium to be a wak ing dream. Others, such as Erasmus Darwin. thought that dreams were protective against delirium. and that the condition was the result of the suppression of dreaming that occurred in physical illnesses such as fcver. John Hunter [4] described delirium as 'a diseased dream aris ing from what may bc called diseased sleep', resulting from the abnormally reduced awarness of the external world. Benjamin Rush [5] thought that all dreaming was a sign of sleep disturbance: 'A dream may be considered as a transient paroxysm of delirium and delirium as a per manent dream.' Heinroth [6] suggested that delirium was a state intermediate bctween sleep and wakefulness. These ideas and observations have contributed to the development of modern theories of dclirium as a disorder of wakcfulness. Delirium has also becn conccptualised as a point on the continuum between alert wakefulncss and coma. In 1817 Greiner [7] described this point as clouding of con sciOllsness, a term that has been used subsequently to refer to both a specific quantitative level of reduced conscious ness, and more generally and qualitatively to an altered mental state with fragmentation of psychic experiencc,

Disturbance of Thinking

From earliest times. delirium has been observed to be associated with impaircd thinking. The term confilsion was introduced in the 19th century by French and Ger man authors to dcscrihe this aspect of the disorder [15]: it is defined as an 'inability to think with one's customary elarity and cohcrcnce' [16]. As Lipowski [I, 2] has notcd, there has heen little systematic study of thinking in delir ium, but some authors have focused on delirium as a dis order of the train of thought due to impaired conscious ness. For example. in French psychiatry, the term delirie refers primarily to disordered thinking [15]. Victor and Adams [17] have proposed a classification of confusional states, including delirium. primary mental confusion, and beclouded dementia. However, as an organising principle confusion is cumbersome. and of limited clinical utility: Lishman [16] advises that the term is a term best avoided in nosology. AClite con/ilsional state is still a popular syno nym for delirium: the history of its description and usage suggests that it has been applied mainly to states of reduced alertncss and psychomotor activity, in contrast to more florid presentations [1].

The Concept of Delirium

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The Course of Delirium

toms rathcr than aetiology. with debate about the 'essen tial' versus the 'accidental' features of the disorder [21]. Increasingly, developments were based upon the careful clinical observation of case series [see 20], and in 1935 Wolff and Curran [22] published their study of the clinical phenomena of delirium, which subsequently became ex tremely influential through quotation in numerous text books. They emphasised the positive features of the con dition, such as excitement. restlessness and hallucina tions; however, as Lipowski [I. 2] has pointed out, theirs was a psychiatric sample and therefore biased in favour of more disturbed cases. The EEG study of Engel and Roma no [13] redressed the balance somewhat. with the observa tion that the majority of cases were in fact hypo- rather

Acutc onset, transient and fluctuating course and vari able outcome arc features of the condition that have been noted by writers from ancient times. Transience was one of the features that distinguished delirium from other excited mental states, such as mania. The outcome of delirium is usually reported as either usually death or recovery, and there has been much interest in prognostic signs. with lethargic states usually regardcd as having a worse outcome. Barrough [3] remarks that if it resolves, it may be followed by loss of memory and reasoning power.

Delirium and External Causation

than hyperactive in nature. Lipowski's book on delirium [I] published in 1980 was an important landmark in the development of the modern concept. On the basis of a detailed historical review (to which this paper is in debted). he argued that it represented a distinct syn drome, and proposed that the term' delirium' should be used in preference to others to describe both the hyperac tive and hypoactive forms of the condition. The most significant development of the concept of delirium in recent times has been the formulation of diag nostic criteria designed to bring some order to the' termi nological chaos' in the area of organic mental syndromes. The intention was to facilitate communication, research and teaching, and to these ends an important function of the criteria was to define the boundary between delirium and dementia, the other common cause of global cogni tive impairment in the modern world. Before publication of DSM-III, psychiatric nosologies followed clinical practice, rather than guiding it. This was particularly true for the International Classification of Diseases, which was designed to allow clinicians around the world to categorise patients with the minimum of for mality or ditTiculty. As a result, there was much use of vague, ill-defined concepts such as confusion. DSM-III was a new departure, with its rule-oriented approach to classification. Drawn up by an expert committee, the emphasis was upon utility. acceptability, consensus, re tention of traditional, established concepts where possi

The association of delirium with physical illness (espe cially fever) and toxins was wcll recognised by ancient authors. Indeed, the presence of fever or cvidence of intoxication or poisoning were evidently diagnostically very important, then as now: the first English medical dic tionary describes mania as 'delirium without fever' [18]. The description of alcoholic delirium tremens in the 19th century [19] was an important development in the delir ium concept, and the clinical stereotype of hyperactive delirium. Another important contribution was made by BonhoctTer [20], whose description of the acute exoge nous psychic reaction types has been influential in shap ing modern ideas about the mental manifestations of physical disease. On the basis of clinical observation, he identified five related psych iatric syndromes (delirium. epileptiform excitement. twilight state, hallucinosis, amentia) that could occur in association with systemic physical illness. No type was diagnostic of any specific physical disease, and all were associated to some extent with disorders of consciousness. This is essentially the modern view, although Bonhoeffer's ideas and terminolo gy have been modified somewhat; for example, it is clear that organic cerebral disease can also give rise to these reaction types.

Towards the Modern Concept of Delirium

ble, and consistency with research data, where this ex isted. DSM-III makes a distinction between organic men tal syndromes and organic mental disorders, where spe cific aetiology is present. However, this breaks down in the case of delirium. since the diagnostic criteria for this syndrome include the presence of a 'specific organic fac tor'. In DSM-IV, the concept of 'organic mental disorder' has been dropped. on the grounds that it implies that

By the late 19th century, the concept of delirium had become established as a transient disorder of intellectual cognitive function, with symptoms of disturbed attention. perception, restlessness, incoherent speech, and delu sions. With the devclopment of descriptive psychopathol ogy, there was a move towards diagnosis in terms of symp-

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Table 1. Essential features of the delirium syndrome (ICD-IO

Table 2. Occurrence of specific symptoms in delirious and non

Research Criteria and DSM-IV) ICD-IO (Research Criteria) 'Clouding of consciousness' and attention Disturbance of cognition (memory. orientation) Psychomotor disturbances Sleep disturbance Rapid onsetltluctuation Evidence of physical cause rapid onselltluctualion evidence of cause DSM-IV disturbance of consciousness, especially attention change in cognition (memory. orientation, language. perception)

delirious patients [23] Delirium Disturbed slecp-wakc cyclc Psychomotor disturbance Memory impairment Perceptual disturbance Incoherent speech 96 93
1 00

on-delirium 65 40 34 3 6

75 76

'non-organic' disorders have no biological basis. The word 'syndrome' is not used, but is implied in the subclas sification of delirium as due to a medical condition. to substance intoxication or withdrawal. or not otherwise specified, which allows for other causes, such as sensory deprivation. ICD-IO retains the concept of 'organic mental disor der', although it is careful to point out that 'organic' means simply that the syndrome so classified can be'at tributed to an independently diagnosable cerebral or sys temic disease or disorder'. Thus, although thc criteria for delirium do not specifically require the presence of an underlying medical condition, its classification in this block would seem to presume it. Table I compares the features of delirium that are regarded as csscntial for diagnosis in ICD-IO and DSM IV, and it is apparent that there is disagreemcnt on which aspects of syndrome are essential, and which supportive. This is not surprising, given that many if not all of the individual symptoms are not specific for delirium [23] (table 2). However, DSM-IV and the ICD-IO Research Criteria agree on four essential criteria: disturbance of consciousness, disturbances of cognition, rapid onset! fluctuating course, and evidence of cause (physical only in the case of ICD-I 0). To what extent do these features dis tinguish delirium from dementia? Disturbance of con sciousncss is described in Lewy body dementia, a condi tion that has a number of features in common with delir ium. Disturbance of cognition is clearly non-specific. Rapid onsct may occur in vascular dementia, and a fluc tuating course is seen in both vascular and Lewy body dementia. It is also wcll-known that the cognitive function of patients with dementia may fluctuate during the course of the day (sundowning). The cause of a delirium may not

be apparent. particularly in elderly patients with signifi cant pre-existing demcntia. What other features are specific to delirium? Although not in the diagnostic criteria, ICD-IO states in its guide lines that the total duration of the condition is less than 6 months. Clearly, duration and outcome are not useful diagnostic pointers. since these arc not known at the out set [24]. However, improvement over time is an impor tant distinction that is drawn between delirium and other conditions such as dementia.

Conclusions

According to Lipowski, 'the concept of delirium has been developed by countless medical writers over two millennia and has reached a state of relative clarity, con sistency and clinical usefulness' [25]. To what extent is our current conceptualisation of delirium clear, consistent and clinically useful? Do the diagnostic criteria describe a coherent syndrome with a distinct pathological substrate? In practical terms, to what extent do these criteria enable us to identify patients with delirium, and to distinguish them from those with other disorders causing cognitive impairment? The current diagnostic criteria for delirium are based upon a long tra dition of observations made in relatively young popula tions, hence the emphasis on positive symptoms and clearly identifiable external causes. However, our ageing population and the large numbers of elderly people with dementia is historically unique, and the traditional con cepts of delirium may not apply in these circumstances. This issue will be discussed further by Macdonald [26] in his contribution to this symposium.

The Concept of Delirium

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