Unravelling the pathophysiology of delirium: a focus on the role of aberrant stress responses

Abstract

Delirium is a common and serious acute neuropsychiatric syndrome with core features of inattention and cognitive impairment, and associated features including changes in arousal, altered sleep-wake cycle, and other changes in mental status. The main risk factors are old age, cognitive impairment, and other comorbidities. Though delirium has consistent core clinical features, it has a very wide range of precipitating factors, including acute illness, surgery, trauma, and drugs. The molecular mechanisms by which these precipitating factors lead to delirium are largely obscure. In this article, we attempt to narrow down some specific causal pathways. We propose a basic classification for the etiological factors: (a) direct brain insults and (b) aberrant stress responses. Direct brain insults are largely indiscriminate and include general and regional energy deprivation (e.g., hypoxia, hypoglycaemia, stroke), metabolic abnormalities (e.g., hyponatraemia, hypercalcaemia), and the effects of drugs. Aberrant stress responses are conceptually and mechanistically distinct in that they constitute adverse effects of stress-response pathways, which, in health, are adaptive. Ageing and central nervous system disease, two major predisposing factors for delirium, are associated with alterations in the magnitude or duration of stress and sickness behavior responses and increased vulnerability to the effects of these responses. We discuss in detail two stress response systems that are likely to be involved in the pathophysiology of delirium: inflammation and the sickness behavior response, and activity of the limbic-hypothalamic-pituitary-adrenal axis. We conclude by discussing the implications for future research and the development of new therapies for delirium.

Figure 1. Inflammation: routes of communication from the periphery to the central nervous system

This illustrates three major routes of by which information on peripheral inflammation is signalled to the central nervous system. There are multiple other potential routes and mediators.

Figure 2. From peripheral insult to delirium: possible pathways

This figure shows some of the pathways linking peripheral inflammation and other insults to changes in the central nervous system occuring on a background of neurodegenerative disease. These signalling pathways are hypothesised to lead to delirium. Abbreviations CRH: corticotropin-releasing hormone; EP1-4: prostaglandin E2 receptors; GCs: glucocorticoids; GR: glucocorticoid receptor; IFN: interferon; IL: interleukin; IL-1RI: interleukin 1RI receptor; LHPA: limbic-hypothalamic-pituitary axis; PAMPs: pathogen-associated molecular patterns; PGE2: prostaglandin E2