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DELIRIUM: DSM-IV CRITERIA FOR DELIRIUM-DISTURBANCE OF COGNITION AND PERCEPTION
The cognitive disturbance in delirium is global and therefore affects reasoning, memory, and language. One of its first signs is disorientation ? initially to time, then to place. It is quite common for hospitalized patients (like their physicians) to make minor errors when asked the day of the week or the date. Most of us can retain the correct information after it has been provided, but delirious patients cannot. As their illness worsens, such patients become disoriented to month, season, and year. Some believe they are at home, at work, or in another city; others confess ignorance of their location. Many delirious patients readily acknowledge that their thinking is confused.
The memory problems characteristic of delirium are also seen early in the course of the syndrome; a patient may forget how long he has been in the hospital or that an important procedure has been scheduled for later in the day. Short-term memory is affected before
long-term memory is, so someone who cannot repeat a sequence of five numbers or recall three unrelated words after several minutes is usually able to give the exact date of his birth. Delirious patients aware of their cognitive deficits sometimes refuse to cooperate with tests of orientation and memory.
In general, the disturbance in language parallels the disturbance in consciousness. Patients with hypoactive-hypoalert delirium usually produce little spontaneous speech, and what is said tends to be vague and fragmentary. Such patients have trouble finding words and naming objects. Written language is more severely impaired than spoken language, and patients may be unable to write a simple sentence. Because comprehension is also disrupted, there is little understanding of abstract ideas or complicated directions. As delirium deepens, the patient often mutters incoherently, then lapses into muteness.
In hyperactive-hyperalert delirium, the patient tends to speak a great deal, but has difficulty sticking to a subject. At times, speech is incomprehensible because it is so rapid and disorganized. Perseveration can occur in both forms of the syndrome: in hypoactive-hypoalert delirium, the patient may continue to give his location when asked the date; in
hyperactive-hyperalert delirium, he may repeat the same word over and over again.
Perceptual disturbances include distortions of stimuli, misidentifications of stimuli (illusions), and perceptions without stimuli (hallucinations). Although any sensory modality, including proprioception, can be affected, disturbances in vision are most common. When visual stimuli are distorted, they may be altered in size, shape, color, number, and movement. Thus, a patient sees his limbs as larger than they are or the straight edges of a vase as undulating lines. Visual illusions are most likely when stimuli are ambiguous (as in a darkened room) or when someone is falling asleep (the hypnagogic state) or waking up (the hypnopompic state). A patient who experiences visual illusions may identify nurses as relatives or pictures on the wall as television screens.
Hallucinations occur in about 50% of patients and are more common in the
hyperactive-hyperalert type of delirium (as seen in patients experiencing alcohol withdrawal) than in the hypoactive-hypoalert type (as seen in patients experiencing organ failure). Visual hallucinations vary, from simple forms to animals to elaborate scenes with life-sized figures. These latter perceptions may be combined with auditory hallucinations, which are second in frequency. Like distortions and illusions, visual hallucinations often begin at night and sometimes occur only when it is dark. Patients with nocturnal hallucinations may not remember them the next morning or may describe them as vivid dreams.
Hallucinations are often accompanied by emotional reactions and sometimes by delusional beliefs. Thus, a delirious patient who hallucinates a threatening animal or a murderer will likely respond with fearfulness and the facial expression and sympathetic nervous system changes appropriate to that state. Such a patient may also become agitated and try to leave the hospital (tearing out catheters in the process) because he believes he is about to be killed.
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