The Physician's Guide to HD Management states, under Delirium:
Delirium, an abnormal change in a patient's level of consciousness, may result from a variety of toxic, structural or metabolic causes. Delirious patients may have waxing and waning of consciousness, may be agitated or lethargic, and frequently have disturbed sleep. Patients in the later stages of HD, are particularly vulnerable to delirium.
Common causes of delirium in HD include prescription medications, particularly benzodiazepines and anticholinergic agents, alcohol or illicit drugs, and medical problems such as dehydration and respiratory or urinary tract infections.
It is important to ask about over the counter medicines such as cold tablets and sleep aids, which patients and families may forget to mention. Subdural hematoma, due to a recognized or unrecognized fall should also be considered if the patient suffers a sudden change in mental status.
Delirium can also come about gradually as an underlying problem worsens. For example, a dehydrated patient may no longer be able to tolerate his usual medication regimen. Delirium can also be mistaken for a number of other conditions in HD. As mentioned previously, it may be accompanied by hallucinations or paranoia.
Clinicians usually expect delirious patients to exhibit agitation or hyperarousal and may overlook the delirious patient who is somnolent
or obtunded. Such patients may seem depressed to their families, but when questioned will not report a low mood.
Physicians should consider a diagnosis of delirium whenever confronted with an acute behavioral change in someone with HD and should review the medication list, examine the patient, and obtain necessary laboratory studies, including a toxicology screen if indicated. Identification and
correction of the underlying cause is the definitive treatment for delirium.
- As dehydration progresses, the tissues tend to shrink, the skin becomes dry and wrinkled, and the eyes become shrunken and the eyeballs soft.
- Fever develops, which may be mild but may become marked as dehydration progresses. Dehydration itself probably affects the temperature regulatory centres in the brain.
- As dehydration and salt loss progress, however, the plasma volume and the output of the heart decrease, with consequent decrease of the blood supply to the skin.
- Sweating decreases and may stop completely, and the main avenue for heat loss is closed. The body temperature may then rise precipitously.
- Dehydration becomes rapidly worse, and death may ensue within two or three days.
- Water is lost from the body by evaporation from the lungs and skin, through the urine, and through the stools, a loss that can become serious in diarrhea.
- Lung and skin losses are increased by work that causes sweating, particularly in a hot, dry climate. The kidneys usually excrete between one and two litres of urine per day, but when dehydration threatens they can conserve water through concentration of the urine.
- The most severe dehydration occurs from diarrhea, with or without vomiting.
- The most efficient lifesaving treatment is intravenous infusion of sterile water containing glucose, sodium chloride, and potassium chloride.
- When swallowing is difficult in extremely ill persons, or when people cannot respond to a sense of thirst because of age or illness or dulling of consciousness, the failure to compensate for the daily loss of body water will rapidly result in dehydration and its consequences.
Water is poorly absorbed when drunk, but a good first aid formula consists of sodium chloride, 3.5 grams; sodium bicarbonate, 2.5 grams; potassium chloride, 1.5 grams; glucose 20 grams (or sucrose 40 grams); and clean water up to one litre. The glucose assists absorption of the sodium and vice versa, and as they are absorbed water is absorbed with them.
Fever and dehyration
(vitamin lack) may be encountered when there are increased losses of vitamins such as occur with chronic severe diarrhea or excessive sweating or when there are increased requirements for vitamins during periods of rapid growth, especially during childhood and pregnancy.
Fever and the endocrine disorder hyperthyroidism are two additional examples of conditions that require higher than the usual levels of vitamin intake. Unless the diet is adjusted to the increased requirements, deficiencies may develop.
Lastly, artificial manipulation of the body and its natural metabolic pathways, as by certain surgical procedures or the administration of various drugs, can lead to avitaminoses. (Diseases involving deficiencies of particular vitamins are discussed in nutrition: Deficiency diseases:
Nutritional Support & Hydration
People who are physically unable to swallow, digest, or absorb food and fluids taken by mouth are at obvious risk of malnutrition and dehydration.
Without nutritional support and hydration, such individuals will become increasingly weakened. As their immune system function is reduced, they may die from infections before death can occur from malnutrition or dehydration.
Malnutrition is caused by inadequate intake of calories, protein, carbohydrates, fats, vitamins, minerals, trace elements, or any combination. The effects of malnutrition depend on its severity, duration, and which specific nutrients are lacking.
The effects include: weight loss, listlessness, and depression; decreased ability to resist infection, to recover from illness, and to withstand surgery or other treatments; impaired wound healing; decreased cardiac and respiratory muscular strength, confusion, coma, and eventual death.
Dehydration is the loss of body water in excess of intake. It is caused by decreasing fluid intake or inability to conserve fluids as a result, for example, of renal disease or severe diarrhea.
Dehydration results in dry mucous membranes; decreased sweat,
saliva, and tears; muscle weakness, rigidity, or tremors; confusion, hallucinations, and delirium; abnormal respiration; coma; and eventual death.
Tube Feeding Techniques and Intravenous Feeding Techniques
The different views about withholding or withdrawing nutritional support and hydration remains a difficult dilemma with important clinical, legal, ethical, financial, and political aspects.
Is withdrawing nutritional support and hydration from a terminally ill or severely debilitated person killing them or merely allowing them to die?
Is the suffering caused by malnutrition, starvation, and dehyration acceptable to the patient?
Is the suffering associated with the aspects of tube or intravenous feeding procedures acceptable?
Since the procedures are covered by Medicare and Medicaid for many patients, is the increased use proper use of limited public funds?
Then, the difficulty of determining which patients are terminally ill adds to this life or death decision.