Doctors at Peking Union Medical College said | The doctor said my old man is "delirious"?

Mr. Li is 75 years old this year. He has always been in good health. Although he occasionally forgets things, it does not affect his daily life. He can be said to be healthy both physically and mentally. After an accidental fall at home, he suffered from severe hip pain. When he went to the hospital for a checkup, he found that he had a femoral neck fracture. He was quickly scheduled for surgery. His family was relieved when they saw the old man return to the ward safely from the operating room.

Unexpectedly, on the night of the operation, while all the other patients in the same room were asleep, Mr. Li became more and more excited, insisted on getting out of bed and walking around, and even talked nonsense. Sometimes he shouted that he wanted to go home, sometimes he mistook the nurse for his son, Xiao Li, and sometimes he said that he was not in the hospital, but was deceived by the nurse and the nurse to the wilderness. He grabbed the doctor on duty and insisted that the doctor protect him. At the same time, he kept calling his son Xiao Li and asked him to call the police. Xiao Li was very anxious after receiving the call at home. Although he had some doubts in his heart, he still rushed to the hospital. After seeing his father in person, he couldn't help but feel more confused. Why did the old man "go crazy" after the operation? After listening to the explanation of the doctor and nurse on duty, Xiao Li learned that these changes in his father were caused by postoperative delirium.

01What are the symptoms of delirium?

Delirium is characterized by a rapidly changing and fluctuating mental state, accompanied by changes in attention, consciousness level, circadian rhythm, cognitive function, etc. Patients may have difficulty concentrating and decreased short-term memory, forget what they just said, or need to repeat it many times to remember. They may also be easily sleepy and fall asleep while talking. Abnormal orientation is often the first thing to be noticed. For example, patients may say the wrong year, month and day, mistake night for day, mistake the hospital for their own home, or recognize the wrong person like Lao Li. There are also hallucinations, delusions and other uncommon mental symptoms that can be seen in delirium. For example, patients may see small animals or relatives who are not around in the room out of thin air, or they may feel that someone is going to hurt themselves like Lao Li, and they are very alert and do not believe in other people's explanations. These manifestations are usually more prominent in the "dead of night". Although there are symptoms during the day, patients often "toss and turn at night and make up for sleep during the day", so the symptoms of delirium during the day are not easy to detect. People with delirium are often unaware of changes in their mental state and have only vague or no memory of the symptoms their family members observe. It is important to note that delirium does not only occur after surgery or in the hospital.

02Why does delirium occur?

Delirium is a special organic encephalopathy syndrome that is affected by many factors . It can be simply understood as brain dysfunction caused by unstable physical condition. Common factors that may cause or aggravate delirium include age (older age), environmental stress (long-term hospitalization, intensive care, surgery, environmental changes, etc.), poor physical condition (severe infection, pain, metabolic disorders, organ failure, etc.), certain types of drugs, long-term bed rest, etc. The stability of brain function is the result of a dynamic balance of multiple factors. Sometimes just the adjustment of a drug will break the original balance and induce the occurrence of delirium.

03Can delirium be cured? How to treat it?

Delirium should have existed since ancient times, but it was not defined by the medical community until the 1980s. Over the past 40 years, scholars from various disciplines at home and abroad have conducted increasingly in-depth research on delirium. Unfortunately, so far, no "special medicine" has been found that is effective for most delirium patients . However, while discovering factors that may affect the state of delirium, the medical community is also accumulating experience in the diagnosis and treatment of delirium.

Generally speaking, the improvement of delirium means that brain function has stabilized , which depends on the improvement of physical condition. Therefore, the most important basis for improving delirium is to adjust the physical condition as soon as possible. Psychiatric consultants often work with the patient's attending physician to sort out the patient's medical condition, identify factors that may affect delirium, and adjust and improve them one by one.

At the same time, family members or caregivers are encouraged to help patients redirect and adjust their circadian rhythms, such as putting a clock in the room; keeping the room appropriately bright during the day, urging patients to increase activities and reduce sleep; reducing light source stimulation at night; etc. Since long-term hospitalization is also a factor that causes delirium to persist, it is usually recommended that patients return to a familiar home environment to continue recovery after their physical condition stabilizes.

Although there is no specific drug that can cure the disease, if the patient in delirium has obvious agitation, mental symptoms, or even aggressive or self-harming behaviors, or needs to use drugs to adjust the circadian rhythm, the doctor may prescribe oral or intramuscular drugs, usually antipsychotic drugs, and sometimes choose temporary protective restraints. After the above "combination punch", most delirium will be improved.

On the day of the operation, Lao Li was restless all night. He was quite quiet the next day and made up for a whole morning’s sleep. He looked much more awake after waking up in the afternoon, and Xiao Li was relieved. But on the second night after the operation, Lao Li "became worse". This time, even Xiao Li was regarded as an "enemy" by his father, and he could not be persuaded or appeased. There was really no other way, so Xiao Li followed the advice of the doctor on duty and coaxed his father to take a sedative antipsychotic drug. Lao Li fell asleep smoothly after taking the medicine. On the third day, he felt a little tired during the day, and continued to take half a pill that night and slept well all night. On the fourth day after the operation, although Lao Li still couldn't remember the date clearly, he was happily discharged from the hospital with his son Xiao Li. After returning home, he did rehabilitation seriously every day, and the delirium never came to Lao Li again.

References:

1. Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, et al. Delirium. Nat Rev Dis Primers (2020) 6. doi:10.1038/s41572-020-00223-4

2. Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. The Lancet (2014) 383: 911-22. doi:10.1016/S0140-6736(13)60688-1

About the author: Geng Wenqi

Attending physician of the Department of Psychology, Peking Union Medical College Hospital, and liaison and consultation professional team physician. Engaged in clinical and research work in mental health in a general hospital.

About the author: Jiang Yinan

Deputy Chief Physician of the Department of Psychology, Peking Union Medical College Hospital, and Head of the Liaison and Consultation Professional Group. Young Member of the Psychiatric Physician Branch of the Chinese Medical Doctor Association.

Audit expert: Hong Xia

Chief physician of the Department of Psychology, Peking Union Medical College Hospital, master's supervisor, and expert of the liaison consultation professional group. Member of the Psychosomatic Medicine Branch of the Chinese Medical Association, and the incoming chairman of the Psychosomatic Medicine Branch of the Beijing Medical Association. Research direction: liaison psychiatry and geriatric psychiatry in general hospitals.

Content from: Geng Wenqi, Jiang Yinan, and doctors at Union Medical College Hospital