Delirium tip sheet looks at this problem in hospitalized older adults

About Liz Seegert

Liz Seegert (@lseegert), is AHCJ’s topic editor on aging. Her work has appeared in, Journal of Active Aging, Cancer Today, Kaiser Health News, the Connecticut Health I-Team and other outlets. She is a senior fellow at the Center for Health Policy and Media Engagement at George Washington University and co-produces the HealthCetera podcast.

Photo: Sheila via Flickr

Delirium is a more common occurrence than many may realize, especially among hospital patients.

Proper diagnosis and treatment are crucial because delirium is linked with increased mortality, longer hospital stays, a need for more nursing care, higher rates of nursing home placement and increased risk of developing dementia after a delirium episode.

As this new AHCJ tip sheet describes, it’s common for delirium among older adults to be mistaken for dementia. However, there are significant differences between the two conditions. Delirium refers to a sudden change in mental function, resulting in confused thinking and reduced awareness of surroundings. It occurs quickly, usually within a couple of hours or days. It’s also usually reversible. Dementia on the other hand, mainly affects memory. Cognitive decline happens gradually over the years and generally is permanent.

While it occurs very rarely in community settings, with as many as 24 percent of all hospitalized adults and up to 87 percent of ICU patients 65 and older may experience delirium. Some 7 million people in the U.S. suffer from the condition annually, and more than 60 percent of those who develop delirium each year during or after a hospital stay are undiagnosed, according to the American Delirium Society. One study found that patients who experienced delirium spent $16,000 to $64,000 in additional medical costs in the year following hospitalization, compared with age, gender and comorbidity-matched controls.

According to the Agency for Healthcare Research and Quality (AHRQ), preexisting cognitive deficiency is the strongest risk factor for delirium. Patients with a higher burden of illness, or multiple conditions like heart disease and diabetes, those who are dehydrated, have vision or hearing problems are at higher risk for developing delirium in a hospital setting. The agency equates the mortality risk of delirium to that of sepsis or an in-hospital acute heart attack. One JAMA article points out that “the hallmark of delirium is the presence of an underlying medical disorder, so it is imperative to discover its cause.” Urinary tract infections, thyroid dysfunction, coronary event, stroke, electrolyte imbalance, and renal insufficiency are all potential causes.

Reaction to medication is among the most common causes of delirium, according to the American Geriatrics Society (AGS). Narcotics, benzodiazepines, anti-cholinergic medications, anti-Parkinson drugs and some anti-epileptic medications may lead to delirium. Depending on the type of delirium, some patients are at risk for overmedication, especially sedation. AHRQ recommends physicians assume all changes in mental status in a hospital setting to be delirium until proven otherwise.

Family members play a crucial role in helping physicians diagnose delirium. They can attest to a loved one’s prior mental status, such as lack of previous confusion and also serve as a focal point for re-orientating and grounding a patient, according to AHRQ. They strongly encourage incorporating family involvement into a patient’s plan of care.

Improved assessment and diagnosis are vital to minimizing delirium. Some hospitals are now implementing the Hospital Elder Life Program (HELP), a comprehensive, evidence-based program designed to provide optimal care and prevent delirium in hospitalized older patients. Daily symptom assessments and modification of activities minimizes confusion, encourages faster recuperation and faster discharge.

Here are some questions to answer in your coverage of this issue:

  • Do your area hospitals have programs to assess or prevent delirium, especially among older patients?
  • What methods are used for assessment?
  • How are care providers trained to diagnose the condition? Are families involved? What proportion of older patients ends up staying longer or are discharged to nursing homes because of delirium-related symptoms?

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