Confusional State (Delirium)
Definition
Confusional state or delirium is an acute disturbance of consciousness and cognition marked by confused thinking, reduced awareness of the surroundings and a fluctuating course.
Causes / Etiology
- Infections (e.g., pneumonia, urinary tract infection)
- Metabolic derangements such as electrolyte imbalance, hypoglycaemia, renal or hepatic failure
- Drugs (sedatives, opioids, anticholinergics) and drug withdrawal (alcohol, benzodiazepines)
- Cerebro‑vascular events, head injury or tumour
- Sleep deprivation and severe pain
Types or Classification
Hyperactive delirium – patient is restless, agitated, may have visual hallucinations.
Hypoactive delirium – patient is drowsy, lethargic, shows little response to stimuli.
Mixed delirium – features of both hyper‑ and hypo‑active types appear at different times.
Pathology (stepwise)
Step 1 → an acute insult (infection, drug, metabolic abnormality) reaches the brain.
Step 2 → neurotransmitter balance is disturbed, especially acetylcholine ↓ and dopamine ↑.
Step 3 → the reticular activating system and cortical networks that maintain attention and orientation become dysfunctional.
Step 4 → the patient develops impaired perception, disordered thought and fluctuating consciousness – the clinical picture of delirium.
Clinical Features
General – sudden onset, fluctuating level of consciousness, disorientation to time/place/person, impaired attention.
Specific –
- Agitation or lethargy (depending on type)
- Hallucinations, especially visual
- Sleep‑wake cycle disturbance (day‑time sleep, night‑time agitation)
- Short‑term memory loss
- Language disturbances (incoherent speech)
Complications
Acute – falls and injuries, aspiration pneumonia, prolonged hospital stay, increased morbidity and mortality.
Chronic – persistent cognitive decline, functional impairment, higher risk of dementia.
Diagnosis / Investigations
Routine tests – complete blood count, serum electrolytes, renal and liver function tests, blood glucose, urinalysis, chest X‑ray.
Special tests – brain CT/MRI to exclude structural lesions, EEG (often shows diffuse slowing), lumbar puncture if meningitis suspected.
Management
General – identify and treat the precipitating cause, ensure a quiet well‑lit environment, re‑orient the patient frequently, maintain hydration and nutrition, avoid restraints if possible.
Modern treatment – low‑dose antipsychotics (haloperidol or atypical agents) for severe agitation or hallucinations; benzodiazepines only for alcohol or benzodiazepine withdrawal. Non‑pharmacological measures such as early mobilization, sleep hygiene and cognitive stimulation are essential.
Dietary advice – regular small meals rich in protein, adequate fluids, avoid caffeine and alcohol, ensure vitamin B‑complex and folate intake.
Homeopathic Therapeutics
Stramonium
- Restlessness with violent agitation
- Visual hallucinations of insects or animals
- Fear of being attacked
- Dilated pupils, hot flushes
- Insomnia with nightmares
- Sudden onset after fright or trauma
Hyoscyamus
- Extreme irritability, violent outbursts
- Delirium with delusions of persecution
- Dry mouth, difficulty swallowing
- Blurred vision, photophobia
- Urinary retention
- Worse in hot weather
Aconitum napellus
- Sudden onset after shock or fright
- Restlessness, anxiety, fear of death
- Palpitations, trembling
- Dry, hot skin, thirst for cold water
- Hallucinations of insects crawling on skin
- Improves with fresh air
Gelsemium
- Lethargic, drowsy delirium with mental dullness
- Weakness, trembling of limbs
- Sluggish speech, difficulty concentrating
- Aversion to work, desire to lie down
- Cold extremities, feeling of heaviness
- Better after rest and warm drinks
Kali carbonicum
- Confusion with poor memory, especially of recent events
- Disorientation to time, place, person
- Anxiety, fear of being alone
- Restlessness at night, insomnia
- Tremors of hands, shaking while writing
- Improves in open air, worsens in closed rooms