June 27, 2017  Last Update: December 21, 2016, 11:10 pm

New York Times article on Delirium: It Sounds Just Like Detox

So is it really "delirium", or is it delirium aided and abetted by substance abuse?

So is it really “delirium”, or is it delirium aided and abetted by substance abuse?

The New York Times is raising awareness of the condition known as “delirium”, citing cases where benzodiazepines (such as the sedative clonazepam) were administered by doctors, and actually made things worse. Delirium can be caused by mild heart attacks or other physical trauma. Those root causes may go undetected, except for the seemingly psychological symptoms characteristic of delirium. So if there is more awareness of delirium as a condition, there may be better treatment, right?

The take away from Jane Brody’s article is…. delirium is a condition? Anti-anxiety drugs and sedatives are not always appropriate for patients presenting symptoms of delirium?

These are choppy waters for a personal health blogger to wade into. While the article succeeds in raising awareness of delirium, it seems to go a bit too far with some assumptions, and may actually confuse things for those dealing with delirium,  dementia, drug-related mental health issues and the mixture of those issues that comes into play when caring for the elderly. And when you add in grandma’s little secret about how badly she needs her benzos … the recommended treatment for delirium starts to sound like a top tier drug detox facility.

What is Delirium?

Delirium is defined in the article as “any sudden change over the course of hours or days in a person’s mental state, such as confusion, hallucinations, disorientation and personality changes like agitation or irritability.” Wow. I can see the problem already. Can we actually treat delirium, or does this description cover just about every one of us when we are under stress, using drugs, or dealing with others we love who are under stress, using drugs, etc?

The article goes on to mention other research on stress (cortisol levels), psychosis, and depression and how they are different yet can be related. The Mayo clinic didn’t write this article about delirium, but they do publish a cut-to-the-chase summary of delirium that seems to be good:

Delirium is a serious disturbance in a person’s mental abilities that results in a decreased awareness of one’s environment and confused thinking. The onset of delirium is usually sudden, often within hours or a few days. Delirium can usually be traced to one or more contributing factors, such as a severe or chronic medical illness, medication, surgery, or drug or alcohol abuse. The symptoms of delirium and dementia are similar, and input from a family member or caregiver may be important for a doctor to make a diagnosis.
- Mayo Clinic

Symptoms of Delirium

What are the symptoms of delirium? Included are hallucinations, agitation, and disorientation. The “sudden change” aspect is important, as is the “temporary” aspect that sets delirium apart from many other mental disorders. Delirium is sometimes known as an “acute confusional state”. I found it interesting that delirium is very common during alcohol withdrawal and withdrawal from sedative use, such as the withdrawal experienced during drug or alcohol detox, a required stage of addiction treatment, but the article didn’t make that connection to addiction treatment.

Causes of Delirium

The Times article mentions connections between delirium and inflammation, heart attack,  and other events like hip surgery, but also cites “links” between delirium and medications, including antihistamines, muscle relaxants, narcotic painkillers and antibiotics among suspects. I found that assumption sloppy. Non-scientific “links” between drugs and the mental state cannot be isolated from the underlying maladies that caused doctors to prescribe those drugs. Certainly if inflammatory response is involved (which is very likely given what we’ve been learning about inflammation’s role in many major diseases), we can’t jump to conclusions about drugs causing or exacerbating delirium just because they are present in the treatment mix. Addiction is a different story, but the author didn’t highlight pain killer addiction, just the medications.

"Conditions that can trigger delirium include urinary tract infection, thyroid or kidney dysfunction, a coronary event or stroke, malnutrition, and an imbalance of electrolytes like sodium or potassium."
- New York Times

Article author Jane Brody also notes that “About one-third of patients over 70 experience delirium during hospitalization. Rates are higher among those having surgery or treatment in the intensive care unit”. She then surmises a connection between that statistic and some of the environmental conditions clinical researchers say can make delirium worse or longer-lasting. Brody at one point asserts  “Just being hospitalized can result in delirium…”, supporting that claim  with a self-reported example from an 85 year old woman who experienced delirium while in the hospital following hip surgery.

Really? “Just being in the hospital” was the cause? Not the massive inflammatory response following something as grossly invasive as hip replacement surgery, or the heavy dose of medications (everything from powerful antibiotics to serious pain killers) administered? Or the mental trauma an 85 year old woman likely faces when hospitalized, alone, following such medical treatment?

Treatment of Delirium and Hey Look, it sounds like Detox

Proper treatment of delirium in emergency room and urgent care settings (including medically-equipped nursing homes) would be great. However, since delirium is a state resulting from a set of conditions, some of which seem horrid and urgent to those experiencing them, we may need a “delirium pill” before our healthcare system can achieve that goal. Medically trying to treat something as diffuse as delirium, without resorting to suppressing the reactions to the delirium (through the use of sedatives, for example), is difficult under any conditions. If sedatives and anti-anxiety drugs make delirium worse, we are in a bit of a pickle. Our healthcare system is based on medication, not care. The New York Times article, despite its flaws, seems to suggest that taking time to actually think and carefully manage a patient experiencing delirium would be best. Duh. Actually taking time to think through maladies and remedies, consider the specifics of how individual patients may be reacting to specific, more subtle things, would lead to better care. I think we know that. We don’t know how to fund it, though.

"...delirium could be prevented in up to 40 percent of cases if doctors, nurses and patients’ families were aware of its causes and made small but meaningful changes in how patients are treated."
- unnamed experts cited by NYT

When thinking through the issues raised by the article on delirium, and the suggestions for treating delirium, I am reminded of a top tier alcohol detox facility (or drug detox facility). Take a look at these suggestions from the “delirium info” page in the new York Times archive. In the section on how to properly treat delirium:

The goal of treatment is to control or reverse the cause of the symptoms. Treatment depends on the condition causing delirium. Diagnosis and care should take place in a pleasant, comfortable, nonthreatening, physically safe environment. The person may need to stay in the hospital for a short time.

Substitute substance addiction and use as the condition causing the delirium, and this this perfectly describes a top tier medical detox facility. Any experienced addition counselor will tell you that the causes of substance addiction vary greatly and include socio-economic stressors, health issues, co-occurring mental health disorders, and very often complicating medical conditions (including the already associated inflammation, surgeries, and of course PAIN).

The Times accepts comments on the article, and I think one commenter “Steve” nailed it with his comment (I added the bold):

“Ms. Brody appropriately mentions medications can cause delirium. She should also have mentioned that withdrawal from medications or other substances can also result in it. As a physician, I have often seen patients, especially elderly ones, who are admitted to hospitals for some other reason and develop delirium because they have stopped taking medications they were taking at home. One of the main culprits is benzodiazepines that can also cause a life-threatening withdrawal syndrome including delirium. Withdrawal from alcohol can also result in delirium. Patients may either forget to tell staff about all their medications at time of hospital admission or, in the case of alcohol, be trying to hide their use.”

Aye, there’s the rub. Substance use, misuse, and abuse entering the main stream, but overlooked, ignored, hidden or simply missed by those addressing the symptoms.Welcome to JohnsAddiction.com, where we try and highlight some of that, because highlighting it can make a difference.

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