Homeopathy treatment for Delirium

Delirium is the commonest organic mental disorder in clinical practice.

Differential diagnosis

Metabolic Causes:

i. Hypoxia, Carbon dioxide narcosis
ii. Hypoglycaemia
iii. Hepatic encephalopathy, Uremic encephalopathy
iv. Cardiac failure, Cardiac arrhythmias, Cardiac arrest
v. Water and electrolyte imbalance (e.g. Water, Na+, K+, Mg++, Ca++)
vi. Metabolic acidosis or alkalosis
vii. Fever Anaemia, Hypovolemic shock
viii. Carcinoid syndrome, Porphyria
viii. Carcinoid syndrome, Porphyria

Endocrine Causes:

i. Hypo- and Hyperpituitarism
ii. Hypo- and Hyperthyroidism
iii. Hypo- and Hyperparathyroidism
iv. Hypo- and Hyperadrenalism

Drugs (Both ingestion and withdrawal can cause delirium) and Poisons:

i. Digitalis, Quinidine, Antihypertensives
ii. Alcohol, Sedatives, Hypnotics (especially barbiturates)
iii. Tricyclic antidepressants, Antipsychotics, Anticholinergics, Disulﬁram
iv. Anticonvulsants,, L-dopa, Opiates
v. Salicylates, Steroids, Penicillin, Insulin
vi. Methyl alcohol, heavy metals, biocides

Nutritional Deﬁciencies:

i. Thiamine, Niacin, Pyridoxine, Folic acid, B12
ii. Proteins Systemic Infections i. Acute and Chronic, e.g. Septicaemia, Pneumonia, Endocarditis

Intracranial Causes:

i. Epilepsy (i.e. postictal states)
ii. Head injury, Subarachnoid haemorrhage, Subdural haematoma
iii. Intracranial infections, e.g. Meningitis, Encephalitis, Cerebral malaria
iv.Migraine

v. Stroke (especially; acute phase), Hypertensive encephalopathy
vi. Focal lesions, e.g. right parietal lesions (such as abscess, neoplasm)

Miscellaneous:

i. Postoperative states (including ICU delirium) ii. Sleep deprivation iii. Heat, Electricity, Radiation.

Pre-existing dementia
Severe medical Illness
History of previous delirium
Visual and hearing impairment
Depression
Abnormal sodium, potassium and glucose
Polypharmacy
Alcohol/ Benzodiazepine use
Use of physical restraint
Use of indwelling catheter
Adding three or more medications
Multiple bed moves
Pain
Surgery
Anaesthesia and hypoxia
Malnutrition and dehydration

The pathophysiology of delirium remains relatively unclear. In general, neuroimaging studies reveal disruptions in higher cortical functioning in multiple disparate areas of the brain, including the prefrontal cortex, subcortical structures, thalamus, basal ganglia, lingual gyri, and frontal, fusiform, and temporoparietal cortex.
Electroencephalographic (EEG) studies also show diffuse slowing of cortical activity.
Theories on the pathogenesis of delirium point to the role of neurotransmitters, inflammation, and chronic stress on the brain. For example, the role of cholinergic deficiency in inducing delirium is strengthened by the clear association of anticholinergic drug use with increased incidence. Studies in surgical patients have demonstrated a dysfunctional interaction between the cholinergic and immune systems in patients who developed postoperative delirium.
Dopaminergic excess is also believed to contribute. Evidence does not appear to support the use of antipsychotic medications (dopamine antagonists) for the prevention or treatment of delirium but is not entirely consistent.
Other neurotransmitters implicated in the pathophysiology of delirium include noradrenaline, serotonin, gamma-aminobutyric acid, glutamate, and melatonin.
Evidence also points to the role of cytokines such as interleukins 1 and 2 and TNF-alpha and interferon in contributing to delirium.
Finally, chronic hypercortisolism, as induced by chronic stress secondary to illness or trauma, may also contribute to delirium initiation.

Experts have identified three types:

Hyperactive delirium- This may be the easiest type to recognize. People with this type may be restless and pace the room. They also may be anxious, have rapid mood swings or see things that aren’t there. People with this type often resist care.
Hypoactive delirium- People with this type may be inactive or have reduced activity. They tend to be sluggish or drowsy. They might seem to be in a daze. They don’t interact with family or others.
Mixed delirium- Symptoms involve both types of delirium. The person may quickly switch back and forth from being restless and sluggish.

Impaired consciousness
Disorientation
Poor attention also concentration
Loss of memory Behaviour
Overactive
Under active Thinking
Muddled (in other words, confused)
Ideas of reference
Delusions Mood
Anxious, irritable
Depressed
Perplexed
Perception
Misinterpretations
Hallucinations, mainly visual
Acute onset, fluctuating course, worse especially, in the evening

Impairment of consciousness is the most important symptom, and is seen as a deficit of attention, concentration, and awareness. Furthermore, Often the patient will not be able to follow or engage in a logical conversation. All in all, The features fluctuate in intensity and are often worse in the evening.
Disorientation: Uncertainty about the time, place, also identity of other people.
Behaviour may be either overactive, with noisiness and irritability, or underactive. Besides this, Sleep is often disturbed.
Thinking is slow and confused but the content is often complex. Ideas of reference also delusions are common.
Mood may anxious, perplex, either irritable or depress and is often labile.
Perception may distort with misinterpretations, illusions, and visual hallucinations. Additionally, Tactile and auditory hallucinations occur but are less frequent.
Memory : Generally, Disturbance of memory affects registration, retention, and recall, as well as new learning.
Insight is impaired.

Delirium symptom changes in severity during its course.
It is essential to assess the patient multiple times, as it is easy to miss a diagnosis, also features like sundowning can be overlooked if the assessment is not done towards the end of the day.

Vital signs:

Pulse: Increased pulse rate may be suggestive of heat failure, myocardial infarction or pulmonary pathology.
Blood pressure: Malignant hypertension is an important cause of delirium, and blood pressure must be monitored if the patient is non compliant with antihypertensive medications.
Low blood pressure may suggest heart failure.

Appearance:

Cherry red color indicates carbon monoxide poisoning,
cyanosis may indicate respiratory or cardiac pathology.
Jaundice may indicate hepatic or biliary pathology.
Edema may be because of liver failure, cardiac failure, renal failure or malnutrition.
Temperature:
Fever may indicate underlying infection.
Conscious level:

Various levels of arousal can be seen in delirium, ranging from stupor to hyperarousal. If the patient appears to have a normal arousal level, attention deficit must be accessed which is very commonly seen in delirium.
Cognitive function using a standardized screening tool, e.g. MoCA, Mini mental state examination or 4AT.
Nutritional status: B12 and folate deficiencies can be assessed on physical examination.
Hydration state: Dehydration as well as an overload of fluids, resulting in hypoxia can cause delirium.
Infectious foci: Careful examination to rule out conditions such as meningitis, encephalitis, pulmonary consolidation etc.
Evidence of intoxication or withdrawal for alcohol, and recreational drugs are an important part of delirium work up. Look for tremors, pupil size, needle tracks etc.

Systemic Examination

Focused examination is necessary to find out underlying etiology.

Neurological examinations: Careful examination must be done to find out neurological causes of delirium, such as cerebrovascular diseases, neurodegenrative disorders such as parkinsonism, Alzheimer, and lewi body dementia.

Many systemic diseases may show neurological manifestations: hepatic encephalopathy causes flapping tremor.
Overdose and intoxication can also effect the central nervous system : opiates causes pinpoint pupils and respiratory depression.
Cardio-vascular examination: Examination of cardiovascular system is crucial in management of delirium.
Careful heart auscultation may reveal underlying pathology.
Frictional rub may suggest pericarditis.
New onset murmur may be indicative of myocardial infarction.
Pulmonary examination: Depressed respiration may be suggestive of drug overdose.
Basal rales may be suggestive of cardiac failure.
wheeze may be because of asthma or COPD.
Increased tactile, vocal fermitus, egophony and dull on percussion may indicate underlying pneumonia.
Abdominal examination:
Ascitis may be suggestive of hepatic, renal or cardiac pathology.
Organomegaly may be indicative of portal hypertension and hepatic pathology.

The diagnosis is clinical and is usually obvious upon talking to the patient. Typically, a standard medical and surgical history is take, rather than a formal psychiatric interview. Often little history can be obtained from the patient, so it is essential to contact relatives, carers, friends, and other clinicians in order to gather the story.
Include a comprehensive list of medications, including over-the-counter remedies, alcohol, also smoking. All in all, a full examination of all physical systems should undertake, including a detailed neurological examination.

Physical investigations should include the following:

Blood for full blood count, urea and electrolytes, liver function tests, thyroid function tests, calcium, phosphate, magnesium, glucose, lactate, troponin, albumin, paracetamol also salicylate, haematinics;
Blood also urine cultures;
Arterial blood gas;
ECG;
Urinalysis;
Chest X-ray;
Consider further tests, e.g. CT head, lumbar puncture, EEG.
Abbreviated Mental Test Score (AMTS): Out of 10 points, a score of 6 or less is taken as delirium.
Mini Mental State Examination (MMSE): 30 points, with more than or equal to 25 taken as normal, mild dementia 21–24, moderate 10–20, and severe less than 10 points.

Psychiatric Disorders
Dementia
Alzheimer disease
Depression
Dementia
Pain
Stroke and transient ischaemic attack
Myocardial infarction
Traumatic head injury
Adrenal crisis
Thyrotoxicosis
Myxoedema coma

Communicate clearly and address sensory impairment
Minimise the patient’s confusion
Encourage mobility and self-care
Optimise nutrition, hydration and regular continence
Minimise risk of injury and agitation
Minimise use of antipsychotic medications
Monitor and respond to pain
Use night-time strategies to promote sleep

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Homeopathic Medicines for Delirium:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

Medicines:

Belladonna:

Generally, Belladonna comes to mind first in delirium. Moreover, It has a violent delirium with loud laughing screaming out, and grinding of the teeth, and, as in all narcotics, a desire to hide or escape. Additionally, The patient is full of fears and imaginings, also the delirium manifests itself by the most positive ebullitions of rage and fury. Besides this, Its general character is one of great activity with great excitement, a hot face and head and oftentimes there is present a sensation as if falling and the patient clutches the air. Sometimes there is a stupor, and when aroused they strike people bark and bite like a dog and are most violent.

Hyoscyamus:

This remedy has not the intensely high degree of maniacal excitement that we find under Stramonium, nor has it the cerebral congestion that characterizes Belladonna. With Hyoscyamus there is an aversion especially, to light, and the patient fears being poisoned; he will sit up in bed, talk and mutter all the time, and look wildly about him. There is a great deal of nervousness, whining, crying also twitching; he tries to escape from imaginary foes; a constant picking at the bedclothes and objects in the air is most characteristic. All in all, It is the remedy for that curious condition of delirium known as “coma vigil.”

Stramonium:

Specifically, with this remedy the delirium is more furious, the mania more acute and the sensorium more perverted and excited than under Belladonna or Hyoscyamus. Furthermore, the patient desires light and company, is very loquacious, garrulous, laughs, sings, swears, prays, curses also makes rhymes. Besides this, He sees ghosts, talks . with spirits and hears voices. Lastly, the head is raised frequently from the pillow, the face is bright· red, also he has a terrified expression; in fact, he seems to see objects rising from every corner to frighten him. Sometimes a silly delirium is present.

Lachesis:

Is characterized by great talkativeness in delirium. It has also the fear of being poisoned; but the Lachesis delirium is of a low form accompanied by dropping of the lower jaw, also a characteristic is that they imagine them- selves under some super-human control.

Cimicifuga:

This remedy has loquacity, with a continual changing of the subject when talking, imaginings of rats, mice, etc. It is usually dependent upon uterine disease.

Veratrum album:

Veratrum has restlessness, and a desire to cut and tear the clothing as in Belladonna; but with this remedy there is a coldness of the surface of the body and a cold sweat. The patient is loquacious, talks very loud and is frightened at imaginary things. It also has a state of frenzy or excitement, during which he indulges in shrieks, in expressions of fright and in violent cursings of those around him.

Phosphorus:

The delirium of Phosphorus is of a low typhoid type, with tendency to haemorrhage and an apathetic, sluggish, stupid state, where the patient is unwilling to talk and answers question slowly. It has also an ecstatic state, in which he sees all sorts of faces grinning at him. He has also imaginary notions, such as imagining that his body is in fragments.

Baptisia:

Generally, The patient imagines his body either in pieces or double: and scattered about, also he has to move constantly to keep the pieces together.

Thuja:

In brief, Here the patient imagines that he is made of glass and moves carefully for fear of breaking.

Absinthium:

Basically, patient has a delirium with a constant desire to move about.

Agaricus:

Dr Bayes praises this remedy highly in the delirium especially, of typhoid fever, where there are constant attempts to get out of bed and tremor of the whole body.

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What is Delirium

Delirium is an acute generalize impairment of brain function, in which the most important feature is impairment of consciousness.

Homeopathic Medicines used by Homeopathic Doctors in treatment of Delirium

Belladonna
Hyoscyamus
Stramonium
Lachesis
Cimicifuga
Veratrum album
Phosphorus
Baptisia
Thuja
Agaricus

What are the main signs of Delirium

Impaired consciousness
Disorientation
Poor attention and concentration
Loss of memory Behaviour
Overactive
Under active Thinking
Muddled (in other words, confused)
Ideas of reference
Delusions Mood
Anxious, irritable
Depressed
Perplexed
Perception
Misinterpretations
Hallucinations, mainly visual

What are the causes of Delirium

Hypoxia
Hypoglycaemia
Hepatic encephalopathy
Cardiac failure
Hypo- and Hyperthyroidism
Digitalis, Quinidine, Antihypertensives
Alcohol, Sedatives, Hypnotics
Anticonvulsants
Proteins Systemic Infections
Epilepsy
Head injury

Psychiatry, Fourth Edition- Oxford Medical Publications – SRG- by Geddes, Jonathan Price, Rebecca McKnight / Ch 26.
A Short Textbook ofPsychiatryby Niraj Ahuja /Ch 3.
Homeopathy in Treatment Of Psychological Disorders by Shilpa Harwani / Ch 17.
Delirium risk factors | CHOPs (nsw.gov.au)
Delirium– Symptoms and causes – Mayo Clinic

Homeopathy treatment for delirium | Homeo doctor in hyderabad