Delirium: Acute Confusional States

Delirium: Acute Confusional States

Zbigniew J. Lipowski

New York: Oxford University Press, 568 pp., 1990

Returning from abroad, ready to tackle this review, I happened to glance at two pieces. One, a subtitle in a London newspaper, said Continental Drifts: Paula Burnett finds Delirium and Dissent at the International Writers’ Conference in Dublin; the other, a description of the present book, under the neurology section. So medicine, particularly psychiatry, has to contend with its symptoms and syndromes being described by common or garden words which the lay public uses any old how, thereby producing mass confusion. Then, when a psychiatrist writes a book to sort it all out credit is given to another speciality.

These chance observations seem suitable points from which to start thinking about delirium. Is it a well-defined clinical entity, is it well taught and which group of physicians has taken it upon themselves to manage it? Given the rate at which it occurs, it certainly seems worth looking at and yet it has not received much attention. Psychiatrists, who often seem to believe that it belongs to them, have not given it anywhere near the attention that they have given to depression and dementia. (Perhaps things have been better since the advent of consultation liaison psychiatry.) In all likelihood delirium has fallen between the cracks of psychiatry, neurology and internal medicine. If quiet, the delirious patient runs the risk of being ignored and, if excitable and repeatedly heading for the fire escape, then the psychiatrist may be called in. All of which does not sound particularly efficient or effective.

However, to put it all into perspective, Dr. Zbigniew Lipowski has written another book on delirium entitled Delirium: Acute Confusional States. It is a successor to Delirium: Acute Brain Failure in Man published in 1980. As the author states “The present version has been completely rewritten and brought up-to-date. While no major advances in the understanding of delirium have occurred in the past decade and the syndrome has continued to be neglected by researchers, progress in the neurosciences and in many other areas relevant to it necessitated a thorough revision of the original text.” Furthermore, “apart from a treatise by Frings that appeared in 1746, not a single book devoted solely to this syndrome had been published before the first version of this book appeared. As far as I could ascertain, it remains the only monograph in English on this subject today. Hopefully, it will stimulate research on delirium and help clinicians treat it.”

An Oxford English Dictionary definition of the word “encyclopedia” is “an elaborate and exhaustive repertory of information on all the branches of some particular art or department of knowledge.” If this definition is acceptable, then the author of this book on delirium can be described as an encyclopedist. Dr. Lipowski, now retired from the University of Toronto, has spent nearly three decades collecting material on different kinds of brain syndrome. Psychiatry is indebted to him for his efforts in this regard and particularly those dealing with the nosology of DSM-III, DSM-IIIR and DSM-IV. This work, completed during his final academic years, must be seen as his magnum opus. As such it is worth describing in some detail.

This book is lengthy, to which Dr. Lipowski attests in the introduction, and like Gaul, has three parts. These are “Delirium: an Organic Mental Syndrome,” “Organic Causes of Delirium,” and “Delirium in Special Patient Populations.” The book reads well and gains from summaries interspersed through the text. The initial historical section covers 2,500 years in 37 pages and is the most entertaining in the book. The author spends some time on the etymology of the term “delirium” which “stems from the Latin word delirare which literally means to go out of the furrow . . . but whose vernacular meaning is to be deranged, crazy, out of one’s wits.” First used in English in the sixteen century it has meant “A mental disorder due to disturbance of brain function and featuring incoherent speech, hallucinations, frenzied excitement and restlessness,” and also “uncontrollable excitement or emotion, ‘frenzied rapture’ or ‘wildly absurd thought or speech’.” While given medical usage in the first century A.D., its meaning was ambiguous, until the end of the eighteenth century, since it could mean insanity or a transient mental disorder, commonly due to fever. Thereafter, the author describes the thinking on the topic as it has occurred since Hippoccrates two and a half millennia ago. This was a demanding task, apparently without precedent, and meant the author often had to go to primary sources for information. While the terminology proved to be inchoate, the author tells of the intellectual excitement of discovering how the concept of the condition grew, albeit still poorly understood, and how it reflects on medical thinking at different periods of history. As such it would be read to advantage by staff and trainee psychiatrists everywhere. Too often these days people believe that psychiatry started with DSM-III and those practising beforehand were flat earthers. So the reader is taken from the ancients, whose term phrenitis can be largely equated with that of delirium, such as Hippocrates, Celsus, Aretaeus, Soranus and Galen, quickly through the “Dark Ages” and into the Renaissance. Thereafter, the medical contributions are given by century, including the first use of the term in England (1592). Many familiar and often surprising names such as Pare, Willis, Quincy, Cheyne, Cullen, Darwin, Hunter, Rush, Dupuytren, Hughlings Jackson, Tuke, Bonhoeffer, Adolf Meyer, Romano and Engel have been in the delirium Hall ofFame. However, the greatest plaudit goes to a relative unknown person, F.C. Greiner, who wrote on the topic in 1817.

In the second chapter Dr. Lipowski is at his best in dealing with the definition of terms. He dismisses previous efforts as “semantic muddle” and by page 41 he is able to offer a definition. “Delirium is a transient, organic mental syndrome of acute onset, characterized by global impairment of cognitive functions, a reduced level of consciousness, attentional abnormalities, increased or decreased psychomotor activity and a disordered sleep-wake cycle.” At the same time the book title is clarified. Thus, “the terms “confusion” and “acute confusional states” should be considered a synonym for delirium, albeit a clumsy and cumbersome one. Once the newly adopted psychiatric nomenclature becomes generally known and accepted, this term may be relegated to the annals of history.” Other terms disposed of are “acute brain syndrome,” “toxic psychosis,” “infective-exhaustive psychosis,” and “encephalopathy.”

Next Dr. Lipowski deals with incidence and prevalence. While he rightly draws our attention to how common delirium is in hospital, 10 to 15 percent of medical and surgical inpatients, and even more in those over 60, there is no mention of nosocomial effects and the extent of acute or subacute delirium in the community. This is of critical importance and it is worthwhile noting that surveys of dementia in the community are confounded by effects due to medication and systemic illness. The population is aging and, as hospital beds further decrease, the elderly will be weathering the effects of illness and treatment at home.

He then proceeds to clinical features, course, treatment and outcome. These are described in detail on pages 55 and 56 and summarized on page 68. The intricacies of the psychopathology in delirium are then spelled out. The etiology of this syndrome is tabled on page 133. The favored mechanisms of this disorder are variable cerebral blood flow, cholinergic blockade and disturbed sleep-wake cycle. Diagnosis is made essentially on clinical features, and identified etiology. Curiously, the MMSE (the most commonly used screening test for cognitive dysfunction in the world) is dismissed as being “of little value in patients over 60 years and older, as well as those with an 8th grade education. Moreover the MMSE has been criticized for its substantial false-negative rate, notably in patients with focal brain lesions and those with mild diffused cognitive dysfunction.” Interestingly, the EEG is not thought to be a specific tool for diagnosis. Differential diagnosis is, of course, between dementia, amnestic syndromes and other organic states and the functional psychiatric disorders. Dr. Lipowski argues that delirium is intelligible by its uniqueness — acute onset, fluctuating and transient course. Treatment is symptomatic: First, ridding the patient of the cause and, second, affording relief with adequate sleep, quiet, hydration and electrolyte balance, sound nursing and supportive psychotherapy. Oddities recommended are electroconvulsive therapy and rapid tranquillization. Who would give elderly patients large doses of haloperidol these days?

This concludes the first section and thereafter he proceeds to “Organic Causes of Delirium” and “Delirium in Special Patient Populations.” So whereas Section 1 is meant to educate and instruct the clinician, the other two sections become quasi-reference books. As such they would be appropriate for reference in acute medical settings.

This is a book of astonishing detail. It deals with a subject which has been known throughout medical history but oddly, despite observations by many famous physicians, has not received much medical attention. Perhaps because the subject is so multidimensional and multifactorial, whereas physicians prefer to deal with specificity.

A key question which psychiatrists should ask themselves is how do CNS disorders, like delirium and dementia, fit into psychiatry. Two recent pieces, Who Owns the Brain? (Eastwood 1990) and Who Owns Research? (Eastwood 1991) provide the basis for an answer.

The plain facts seem to be that psychiatrists are mostly bright, nice people who largely eschew research. They tend to be in the vanguard of being nice to patients. This is no bad thing given the hi-tech and rapid turnover of patients in medicine. However, psychiatry has what a recent article (Trent 1991) called an image problem; and, indeed, a relevance problem. It has been said that a good psychiatrist is someone who can live with ambiguity. While this might imply thoughtfulness and tolerance, conversely it could mean blissful ignorance. So the present day psychiatrist has to be seen to be solving problems. This has started in the academic centers where excellence and accountability have become key words. Research endeavor and academic standing will be rewarded financially. This may be a fillip to academic psychiatry. So may Bill C-22 which will encourage more drug trials. However, will there be better basic and clinical research? Currently, in the postgraduate schools there are more Ph.D’s than M.D.’s doing research in psychiatry. Amongst the M.D.’s doing brain research, neurologists seem to be foremost. There are 18 centers in the Canadian Study of Health and Aging (an epidemiological study of dementia) and only two of the principal investigators are psychiatrists. The rest are neurologists, geriatric physicians and Ph.D’s. Again looking at a multi-center trial of a cognitive enhancer” there are three psychiatrists amongst the 20 principal investigators. These are two of presumably a number of current dementia studies but they are mentioned because they are national studies. While there must be ongoing studies of delirium in Canada, I have no knowledge of these or the contribution of the different specialities. It would be nice to know and those involved should write to the editor of the Journal.

When it comes to clinical practice, there appears to be a distinct move amongst younger psychiatrists towards consultation liaison work, which obviously includes delirium. At the same time there is less interest in inpatient work. With about 3,000 psychiatrists in the country this need not be. Would it be mischievous to suggest consultation liaison pays better than inpatient work? (Physicians, psychiatrist included, used to see inpatient beds as being valuable for rich clinical, teaching and research material. This no longer appears to hold) So delirium is in the hands of a new breed of younger doctors. How many peer-reviewed grants in the area of delirium do these young doctors hold?

Dementia and delirium are twin problems. They both involve major disruption of the brain with the first being permanent and the second, potentially, temporary. Dementia has attracted more interest from psychiatry, although delirium may be as large a clinical problem. Dementia seems to have an attraction for psychiatrists, neurologists, neuropsychologists and neuropathologists, but it is not clear that delirium is equally engaging. Delirium, in fact, seems to be a “Cinderella.” It is an area that apparently does not excite those in physiology, epidemiology and pathology, so who will take on this topic? Is the subject too generic? Is the area too medical for most psychiatrists? Is there too much basic science there for psychiatrist? All possibly yes. However, since there is going to be so much delirium around, since its presentation is so frequently behavioral and since there is a considerable differential diagnosis, including a number of psychiatric disorders, it is imperative that psychiatry shapes up and sees the patients and does sound clinical investigation.

This book will charm many academic psychiatrists and may lead consultation-liaison psychiatrists to sharpen their measuring tools. Some will be left wondering why depression and dementia have attracted more research time than delirium and why this is only the third book written on this topic in English in 250 years. Hopefully, it will engender more interest in the field but at $97.50 it may only appeal to a specialized audience.