The delirium experience: A review

doi:10.1016/j.jpsychores.2008.05.017

Journal of Psychosomatic Research

Volume 65, Issue 3, September 2008, Pages 223-228

https://doi.org/10.1016/j.jpsychores.2008.05.017 Get rights and content

Abstract

While the adverse medical complications and consequences of delirium has been well studied, the same is not true of the psychological morbidity associated with the condition. A better understanding of what it is like to be delirious has the potential to improve recognition, management and treatment of delirium. This article examines the literature relating to the experience of delirium from the perspective of patients, families, and staff. Finally, suggestions for further work that might advance might advance our understanding of these issues are outlined.

Introduction

Delirium is a common neuropsychiatric illness characterized by disturbances of consciousness, attention, cognition, and perception that develop over a short period of time and tend to fluctuate during the course of the day [1]. While the adverse medical complications and consequences of delirium has been well studied, the same is not true of the psychological morbidity associated with the condition.

Many reviews of delirium suggest that delirium is an unpleasant condition for patients [1], [2]. There are several reasons why this might be so. Perceptual disturbances and delusions are important symptoms of delirium. Behavioral problems and agitation during delirium suggest patient distress. Emotional disturbance is also commonly reported and is an essential feature in the International Statistical Classification of Diseases, 10th Revision criteria for delirium [3]. The opinions of expert clinicians have differed regarding the extent to which people with delirium might recall their experiences [4], [5]. However, people who have recovered from the condition have written of the unpleasantness of their experience [6], [7], and psychological sequelae and even posttraumatic stress disorder (PTSD) have been reported [6], [8], [9]. A better understanding of what it means to a patient to be delirious has the potential to improve recognition, management, and treatment of delirium.

The impact of delirium may extend beyond the patient. Nurses are the staff in most frequent and intimate contact with patients, and it is generally acknowledged that caring for delirious patients may be difficult, stressful, and at times, dangerous [10]. It is also accepted that delirium adds to the upset for families of having a loved one suffering from the underlying illness. While nurses and, often, families may have an important role in caring for and comforting delirious patients, it is also important that their own needs and stresses are recognized and minimized.

These are important issues. However, it was our view that there was a paucity of systematic empirical research to illuminate our understanding of the experience of delirium from the perspective of patients, families, and nurses. In this review, we examine and synthesize the relevant literature. Finally, suggestions for further work that might advance our understanding of these issues are outlined.

Section snippets

Methods

A systematic literature search using the terms delirium in combination with each of mental recall, posttraumatic stress disorders, nurse-patient relations, attitude of health personnel and professional–family relations was carried out using the National Library of Medicine PubMed and CINAHL databases on papers published in English between 1980 [when Diagnostic and Statistical Manual of Mental Disorder, Third Edition (DSM-III) criteria for delirium were introduced] and April 2008. Reference

Emotional feelings

The dominant emotions in many studies were fear, anxiety, and of feeling threatened during the episode of delirium [11], [12], [13], [14], [15], [16], and these feelings may be directly related to patients' aggressive behavior [16]. Feelings of hopelesness, loneliness, and depression are also common [16], [17]. For some patients, a disinterested perplexity, in which they observe events as through a mist, may be the most common mood experienced [11]. Less commonly, patients report enjoying their

Impact of delirium on families and staff

Breitbart et al. [26] reported that 76% of spouses/caregivers and 73% of nurses reported severe distress related to delirium. Mean distress levels were significantly higher for spouses/caregivers than for nurses caring for the patients and even for the patients themselves. Hyperactive delirium and poor functional status were major predictors of family distress, while severe delirium and perceptual disturbances were the strongest predictors of nursing distress.

Qualitative studies of professional

Recommendations for further research

The qualitative literature provides many insights into how distressing and disturbing delirium is for many patients. One obvious question for the future is how this information can be used to improve patient care and to minimize the distress for patients. Different authors have reached conflicting conclusions. Schofield [16] argued that reality orientation is likely to be effective, but Fagerberg and Jonhagen [13] noted that this can exacerbate patients' feelings of hopelessness and isolation.

Acknowledgments

We are grateful to Professor Ingegerd Fagerberg, Karolinska Institutet, Stockholm, Sweden for providing a pre-publication copy of Ref. [17].

References (27)

InouyeSK
The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients
Am J Med
(1994)
DiMartiniA et al.
Posttraumatic stress disorder caused by hallucinations and delusions experienced in delirium
Psychosomatics
(2007)
LaitinenH
Patients' experience of confusion in the intensive care unit following cardiac surgery
Intensive Crit Care Nurs
(1996)
AnderssonEM et al.
Nurses' experiences of the encounter with elderly patients in acute confusional state in orthopaedic care
Int J Nurs Stud
(2003)
MoritaT et al.
Terminal delirium: recommendations from bereaved families' experiences
J Pain Symptom Manage
(2007)
BreitbartW et al.
The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses
Psychosomatics
(2002)
MeagherDJ et al.
Delirium phenomenology illuminates pathophysiology, management, and course
J Geriatr Psychiatry Neurol
(1998)
World Health Organisation
The ICD-10 classification of mental and behavioural disorders. Diagnostic criteria for research
(1992)
JolleyD
Acute confusional states in the elderly
RothM
Clinical perspectives
Int Psychogeriatr
(1991)

FlemingerS

Remembering delirium

Br J Psychiatry

(2002)

CrammerJL

Subjective experience of a confusional state

Br J Psychiatry

(2002)

GriffithsRD et al.

Delirium, cognitive dysfunction and posttraumatic stress disorder

Curr Opin Anaesthesiol

(2007)

Cited by (113)

Use of Olanzapine by Subcutaneous Catheter to Control Refractory Delirium: A Case Report
2024, Revista Colombiana de Psiquiatria
El delirium es el trastorno neuropsiquiátrico más común en los pacientes adultos mayores, con aumento en su presentación al final de la vida. Dentro de los tratamientos farmacológicos se puede encontrar el haloperidol como primera línea, con uso limitado por efectos extrapiramidales y cardiovasculares. Como alternativa se encuentra la olanzapina, sin tener evidencia clara y precisa sobre administración subcutánea en especial en un entorno paliativo.
Presentación del caso Paciente de 93 años con evento cerebrovascular agudo, que conllevó a una declinación funcional catastrófica, quien presentó un delirium hiperactivo de difícil manejo, sin respuesta a dos primeras líneas de tratamiento, incluido el haloperidol, en quien se logra control de síntomas con olanzapina por vía subcutánea.
La olanzapina por vía subcutánea es una opción terapéutica para el tratamiento del delirium en el contexto paliativo, cuando el objetivo de atención es el bienestar, y el fin de vida es inminente.
Delirium is the most common neuropsychiatric disorder in elderly patients, with an increase in its presentation at the end of life. Within pharmacological management, haloperidol is considered as the first line, with limited use due to extrapyramidal and cardiovascular effects. Olanzapine is an alternative, without having clear and precise evidence on subcutaneous administration, especially in a palliative setting.
A 93-year-old patient with an acute cerebrovascular event, which led to a catastrophic functional decline, who presented as a symptom of hyperactive delirium that was difficult to manage without response to two first lines of management, including haloperidol, in whom control of symptom with subcutaneous olanzapine.
Subcutaneous olanzapine is a therapeutic option for the management of delirium in the palliative context, when the goal of care is comfort, and the end of life is imminent.
Experiences of relatives of patients with delirium due to an acute health event - A systematic review of qualitative studies
2023, Applied Nursing Research
Evaluate relatives' experience of delirium due to an acute health event in a loved person and to compile practical suggestions for health care professionals from these synthesized results.
Delirium resulting from an acute health event places patients at increased risk for prolonged hospitalization and mortality. A delirium episode also affects family members who may assist in the diagnosis and recovery from this condition.
Qualitative studies of family members or other caregivers who witnessed patient delirium in a clinical setting were included if they had appropriate verbatim evidence. Studies dealing exclusively with delirium in the context of dementia, cancer, palliative care, or drug dependence were excluded, and if quotes could not be clearly allocated to relatives.
A systematic review of qualitative studies adapted from the Joanna Briggs Institute meta-aggregation approach. A systematic literature search was conducted in CINAHL complete®, MEDLINE®, and several dissertation databases in September 2022.
Eight qualitative studies based on semi-structured interviews were included. In total 75 findings from 105 relatives were aggregated into 13 categories. Finally, three synthesized findings reveal suggestions for health care professionals: providing information adequately, communication and integration during health care and understanding relatives' perspective on delirium experience.
The identified burdens and needs of relatives should be considered by health care professionals to enhance the delirium experience for them, thus improving patient care by involving relatives with a better understanding.
What Is Delirium and How Should It Be Managed?
2023, Evidence-Based Practice of Palliative Medicine, Second Edition
Delirium is a transient, often reversible cause of cerebral dysfunction that can manifest clinically with a wide range of neuropsychiatric abnormalities. The clinical hallmarks of delirium are decreased attention span and waxing and waning confusion. Delirium is associated with numerous negative outcomes, including increased risk of mortality, longer hospital stays, and decreased ability to care for self, which increases both caregiver burden and nursing home placement. Screening for delirium must be done at the bedside; there are no laboratory values or scans that indicate that a patient is delirious. Therefore, to make a diagnosis of delirium, it is essential to obtain a thorough history and perform a comprehensive physical examination. All delirium treatment decisions should be made with patient and family goals of care in mind. Delirium has been shown to cause distress to everyone it touches and can have long-lasting mental health effects on bereaved family members.
Delirium-related distress in the ICU: A qualitative meta-synthesis of patient and family perspectives and experiences
2021, International Journal of Nursing Studies
Better understanding of patient and family member experiences of delirium and related distress during critical care is required to inform the development of targeted nonpharmacologic interventions.
To examine and synthesize qualitative data on patient and family member delirium experiences and relieving factors in the Intensive Care Unit (ICU).
We conducted a systematic review and qualitative meta-synthesis. Eligible studies contained adult patient or family quotes about delirium during critical care, published in English in a peer-reviewed journal since 1980. Data sources included PubMed, Embase, CINAHL, PsycINFO, Web of Science, Cochrane and Clinicaltrials.gov.
Systematic searches yielded 3238 identified articles, of which 14 reporting 13 studies were included. Two reviewers independently extracted data into a Microsoft Excel spreadsheet. Qualitative meta-synthesis was performed through line-by-line coding of relevant quotes, organization of codes into descriptive themes, and development of analytical themes. Five patients/family members with experience of ICU delirium contributed to the thematic analysis.
Qualitative meta-synthesis resulted in four major themes and two sub-themes. Key new patient and family-centric insights regarding delirium-related distress in the ICU included articulation of the distinct emotions experienced during and after delirium (for patients, predominantly fear, anger and shame); its ‘whole-person’ nature; and the value that patients and family members placed on clinicians’ compassion, communication, and connectedness.
Distinct difficult emotions and other forms of distress are experienced by patients and families during ICU delirium, during which patients and families highly value human kindness and empathy. Future studies should further explore and address the many facets of delirium-related distress during critical care using these insights and include patient-reported measures of the predominant difficult emotions.
Reward contingency gates selective cholinergic suppression of amygdala neurons
2024, eLife
Nurses' encounters with patients having end-of-life dreams and visions in an acute care setting – A cross-sectional survey study
2024, Journal of Advanced Nursing

View all citing articles on Scopus

View full text

Review ArticleThe delirium experience: A review

Abstract

Introduction

Section snippets

Methods

Emotional feelings

Impact of delirium on families and staff

Recommendations for further research

Acknowledgments

Am J Med

Psychosomatics

Intensive Crit Care Nurs

Int J Nurs Stud

J Pain Symptom Manage

Psychosomatics

Delirium phenomenology illuminates pathophysiology, management, and course

J Geriatr Psychiatry Neurol

The ICD-10 classification of mental and behavioural disorders. Diagnostic criteria for research

Acute confusional states in the elderly

Clinical perspectives

Int Psychogeriatr

Remembering delirium

Br J Psychiatry

Subjective experience of a confusional state

Br J Psychiatry

Delirium, cognitive dysfunction and posttraumatic stress disorder

Curr Opin Anaesthesiol

Review Article
The delirium experience: A review