Der Nervenarzt

, Volume 85, Issue 4, pp 427–436 | Cite as

Delir in der Neurologie

Diagnose, Behandlung und Prognose
Leitthema

Zusammenfassung

Das Delir ist ein häufiges, akutes neuropsychiatrisches Syndrom. Es ist gekennzeichnet durch gleichzeitig bestehende Störungen des Bewusstseins und der Aufmerksamkeit, der Wahrnehmung, des Denkens, des Gedächtnisses, der Psychomotorik, der Emotionalität und des Schlaf-Wach-Rhythmus. Das Delir durch Alkohol- oder Medikamentenentzug ist nicht Gegenstand dieser Übersichtsarbeit. Für ein Delir gibt es typische Risikofaktoren und Auslöser, die in der gemeinsamen Endstrecke, einer globalen Hirnfunktionsstörung, enden. Die wichtigsten Risikofaktoren sind höheres Alter, kognitive Defizite oder Demenz, sensorische Defizite, Multimorbidität und Polypharmazie. Ein Delir ist immer Ausdruck einer oder mehrerer zugrunde liegender Pathologien, die es zu identifizieren gilt. In der Neurologie spielen sowohl primäre Auslöser des Delirs wie z. B. ein Schlaganfall oder ein epileptischer Anfall eine Rolle. Bei multimorbiden Pateinten sind aber auch sekundäre Auslöser wie metabolische Faktoren oder Medikamentennebenwirkungen von besonderer Bedeutung. Wichtig in der Prophylaxe des Delirs sind nichtmedikamentöse Maßnahmen, durch welche die Prognose verbessert werden kann. Das Delir ist mit einer erhöhten Mortalität assoziiert. Nach einem Delir kann es bei den Patienten längerfristig zu einer Entwicklung kognitiver Defizite und funktioneller Einschränkungen kommen.

Schlüsselwörter

Delir Risikofaktoren Auslöser Prävention Therapie 

Delirium in patients with neurological diseases

Diagnosis, management and prognosis

Summary

Delirium is a common acute neuropsychiatric syndrome. It is characterized by concurrent disturbances of consciousness and attention, perception, reasoning, memory, emotionality, the sleep-wake cycle as well as psychomotor symptoms. Delirium caused by alcohol or medication withdrawal is not the subject of the current review. Specific predisposing and precipitating factors have been identified in delirium which converge in a common final pathway of global brain dysfunction. The major predisposing factors are older age, cognitive impairment or dementia, sensory deficits, multimorbidity and polypharmacy. Delirium is always caused by one or more underlying pathologies which need to be identified. In neurology both primary triggers of delirium, such as stroke or epileptic seizures and also secondary triggers, such as metabolic factors or medication side effects play a major role. Nonpharmacological interventions are important in the prevention of delirium and lead to an improvement in prognosis. Delirium is associated with increased mortality and in the long term the development of cognitive deficits and functional impairment.

Keywords

Delirium Predisposing factors Precipitating factors Prevention Therapy 

Literatur

  1. 1.
    American Psychiatric Association (1999, guideline watch 2004) Practice guideline for the treatment of patients with delirium. Am J Psychiatry 156:1–20Google Scholar
  2. 2.
    Bickel H (2007) Die deutsche Version der Confusion Assessment Method (CAM) zur Diagnose des Delirs. Psychosom Konsiliarpsychiatr 3:224–228CrossRefGoogle Scholar
  3. 3.
    Boettger S, Friedlander M, Breitbart W et al (2011) Aripiprazole and haloperidol in the treatment of delirium. Aust N Z J Psychiatry 45:477–482PubMedCrossRefGoogle Scholar
  4. 4.
    Breitbart W, Gibson C, Tremblay A (2002) The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses. Psychosomatics 43:183–194PubMedCrossRefGoogle Scholar
  5. 5.
    Chan TC, Luk JK, Shea YF et al (2011) Continuous use of antipsychotics and its association with mortality and hospitalization in institutionalized Chinese older adults: an 18-month prospective cohort study. Int Psychogeriatr 23:1640–1648PubMedCrossRefGoogle Scholar
  6. 6.
    Cole MG, Mccusker J, Bellavance F et al (2002) Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. CMAJ 167:753–759PubMedCentralPubMedGoogle Scholar
  7. 7.
    Devlin JW, Roberts RJ, Fong JJ et al (2010) Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study. Crit Care Med 38:419–427PubMedCrossRefGoogle Scholar
  8. 8.
    Fong TG, Tulebaev SR, Inouye SK (2009) Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol 5:210–220PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Francis J, Young GB (2012) Diagnosis, prevention and treatment of delirium and confusional states. In: Aminoff JM, Schmader KE (Hrsg) UpToDate®Google Scholar
  10. 10.
    Girard TD, Pandharipande PP, Carson SS et al (2010) Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: the MIND randomized, placebo-controlled trial. Crit Care Med 38:428–437PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Hufschmidt A, Shabarin V (2008) Diagnostic yield of cerebral imaging in patients with acute confusion. Acta Neurol Scand 118:245–250PubMedCrossRefGoogle Scholar
  12. 12.
    Inouye SK (2006) Delirium in older persons. N Engl J Med 354:1157–1165PubMedCrossRefGoogle Scholar
  13. 13.
    Inouye SK, Bogardus ST Jr, Charpentier PA et al (1999) A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 340:669–676PubMedCrossRefGoogle Scholar
  14. 14.
    Inouye SK, Charpentier PA (1996) Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 275:852–857PubMedCrossRefGoogle Scholar
  15. 15.
    Joshi A, Krishnamurthy VB, Purichia H et al (2012) „What’s in a name?“ Delirium by any other name would be as deadly. A review of the nature of delirium consultations. J Psychiatr Pract 18:413–418PubMedCrossRefGoogle Scholar
  16. 16.
    Kiely DK, Jones RN, Bergmann MA et al (2007) Association between psychomotor activity delirium subtypes and mortality among newly admitted post-acute facility patients. J Gerontol A Biol Sci Med Sci 62:174–179PubMedCrossRefGoogle Scholar
  17. 17.
    Krauss G, Theodore WH (2010) Treatment strategies in the postictal state. Epilepsy Behav 19:188–190PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Landefeld CS, Palmer RM, Kresevic DM et al (1995) A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med 332:1338–1344PubMedCrossRefGoogle Scholar
  19. 19.
    Leentjens AF, Rundell J, Rummans T et al (2012) Delirium: an evidence-based medicine (EBM) monograph for psychosomatic medicine practice, comissioned by the Academy of Psychosomatic Medicine (APM) and the European Association of Consultation Liaison Psychiatry and Psychosomatics (EACLPP). J Psychosom Res 73:149–152PubMedCrossRefGoogle Scholar
  20. 20.
    Leslie DL, Inouye SK (2011) The importance of delirium: economic and societal costs. J Am Geriatr Soc 59(Suppl 2):S241–S243PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Lonergan E, Luxenberg J, Areosa Sastre A (2009) Benzodiazepines for delirium. Cochrane Database Syst Rev CD006379Google Scholar
  22. 22.
    Lorenzl S, Fusgen I, Noachtar S (2012) Acute confusional states in the elderly – diagnosis and treatment. Dtsch Arztebl Int 109:391–399PubMedCentralPubMedGoogle Scholar
  23. 23.
    Maldonado JR (2013) Neuropathogenesis of delirium: review of current etiologic theories and common pathways. Am J Geriatr Psychiatry 21:1190–1222PubMedCrossRefGoogle Scholar
  24. 24.
    Marcantonio ER, Flacker JM, Wright RJ et al (2001) Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 49:516–522PubMedCrossRefGoogle Scholar
  25. 25.
    Martin J, Heymann A, Basell K et al (2010) Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care – short version. Ger Med Sci 8:Doc02PubMedCentralPubMedGoogle Scholar
  26. 26.
    Mccusker J, Cole M, Abrahamowicz M et al (2001) Environmental risk factors for delirium in hospitalized older people. J Am Geriatr Soc 49:1327–1334PubMedCrossRefGoogle Scholar
  27. 27.
    Mcmanus J, Pathansali R, Stewart R et al (2007) Delirium post-stroke. Age Ageing 36:613–618PubMedCrossRefGoogle Scholar
  28. 28.
    National Clinical Guideline Centre (2010, evidence update 2012) Delirium: diagnosis, prevention and management (Clinical Guideline 103). In: National Clinical Guideline Centre, LondonGoogle Scholar
  29. 29.
    Ostgathe C, Gaertner J, Kotterba M et al (2010) Differential palliative care issues in patients with primary and secondary brain tumours. Support Care Cancer 18:1157–1163PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Punja M, Pomerleau AC, Devlin JJ et al (2013) Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis: an etiology worth considering in the differential diagnosis of delirium. Clin Toxicol 51:794–797CrossRefGoogle Scholar
  31. 31.
    Ruiz Bajo B, Roche Bueno JC, Seral Moral M et al (2013) Incidence and predictive factors of delirium in hospitalised neurological patients. Neurologia 28:356–360CrossRefGoogle Scholar
  32. 32.
    Schusse CM, Peterson AL, Caplan JP (2013) Posterior reversible encephalopathy syndrome. Psychosomatics 54:205–211PubMedCrossRefGoogle Scholar
  33. 33.
    Schwartz TL, Masand PS (2002) The role of atypical antipsychotics in the treatment of delirium. Psychosomatics 43:171–174PubMedCrossRefGoogle Scholar
  34. 34.
    Siddiqi N, House AO, Holmes JD (2006) Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing 35:350–364PubMedCrossRefGoogle Scholar
  35. 35.
    Teslyar P, Stock VM, Wilk CM et al (2013) Prophylaxis with antipsychotic medication reduces the risk of post-operative delirium in elderly patients: a meta-analysis. Psychosomatics 54:124–131PubMedCrossRefGoogle Scholar
  36. 36.
    Velez A, Mckinney JS (2013) Reversible cerebral vasoconstriction syndrome: a review of recent research. Curr Neurol Neurosci Rep 13:319PubMedCrossRefGoogle Scholar
  37. 37.
    Warshaw G, Tanzer F (1993) The effectiveness of lumbar puncture in the evaluation of delirium and fever in the hospitalized elderly. Arch Fam Med 2:293–297PubMedCrossRefGoogle Scholar
  38. 38.
    Witlox J, Eurelings LS, De Jonghe JF et al (2010) Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA 304:443–451PubMedCrossRefGoogle Scholar
  39. 39.
    Zampieri FG, Park M, Machado FS et al (2011) Sepsis-associated encephalopathy: not just delirium. Clinics 66:1825–1831PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  1. 1.Universitätsklinik für Biologische Psychiatrie, Department für PsychiatrieMedizinische Universität InnsbruckInnsbruckÖsterreich

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