By Liz Seegert
Delirium is among the most common mental disorders seen in older adults, with more than 7 million hospitalized Americans suffering from the condition each year. It is associated with many complex underlying medical conditions and can be hard to recognize. It can also be life threatening, especially for the elderly.
Delirium refers to a sudden change in mental function, resulting in confused thinking and reduced awareness of surroundings. It can lead to aggression and agitation, or sleepiness and inactivity, or sometimes both. Unlike dementia, which occurs gradually over time, the onset of delirium is usually rapid — within hours or a few days. The condition is especially common among hospitalized older adults or those in nursing homes and may require immediate medical intervention.
Sudden confusion is different from other common changes in thinking that can happen as we age. With a condition such as dementia, confusion happens slowly, over time. However, prompt medical treatment should be sought if an older person exhibits unexpected disorientation, or if their thinking abilities change quickly and without warning. An abrupt change in cognitive function is not normal in older adults. This type of rapid-onset confusion may be the first sign that the person has another illness or indicate a life-threatening condition according to mental health experts.
Signs and symptoms
The American Psychological Association Diagnostic and Statistical Manual, version 5 (DSM-V) lists common signs and symptoms of delirium, including:
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Disturbances in attention (reduced ability to direct, focus, sustain, and shift attention) and awareness which develops over a short period (usually hours to days), which represents a change from baseline, and tends to fluctuate during the course of the day.
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Additional disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, or perception).
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Disturbances which are not better explained by another preexisting, evolving or established neurocognitive disorder, and do not occur in the context of a severely reduced level of arousal, such as coma.
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Evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication or withdrawal, or a medication side effect.
Delirium is rare in community-based settings, affecting only 1 percent to 2 percent of the general population. However, that rate jumps to 14 percent to 24 percent among admitted hospital patients and may be as high as 56 percent during the course of a hospital stay, according to researchers at the Institute for Aging Research, Hebrew Senior Life and the Harvard Medical School. Among the postoperative population of adults age 65-plus, it’s even higher. Among elderly admitted to intensive care units, it can climb to 87 percent. While delirium is often transient and may disappear after hospital discharge, that’s not always the case. It can result in long-term cognitive changes.
Delirium triggers
The American Geriatrics Society (AGS) points out that reaction to medication, especially new medication, is one of the most common causes of delirium. Common medications that can cause delirium include narcotics, benzodiazepines, anti-cholinergic medications, anti-Parkinson drugs, and some anti-epileptic medications. Diuretics, commonly used in heart patients, pull excess fluid from the body. However, that can lead to dehydration, another risk factor.
Delirium can occur in anyone who is seriously ill. However, older age is a strong risk factor. Additional risks include:
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Dementia
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Prior instances of sudden confusion
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Problems seeing or hearing
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Not getting enough to eat or drink
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Chronic physical illness or pain
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Alcohol or drug use
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Depression
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Other problems in the brain or nervous system
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Functional disability
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Acute infection
Delirium itself may cause a fall due to the confusion, excitability, inattention, and misunderstanding of environmental cues that occur when a person experiences delirium, according to the AGS. This can lead to bone fractures and further hospitalization, ultimately compounding the situation.
According to the Mayo Clinic, there are three types of delirium:
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Hyperactive delirium. Probably the most easily recognized type, this may include restlessness (for example, pacing), agitation, rapid mood changes or hallucinations.
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Hypoactive delirium. This may include inactivity or reduced motor activity, sluggishness, abnormal drowsiness or seeming to be in a daze.
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Mixed delirium. This includes both hyperactive and hypoactive symptoms. The person may quickly switch back and forth from hyperactive to hypoactive states.
The U.S. Department of Veterans Affairs cautions family members to be aware of signs and symptoms of delirium and seek immediate medical attention for their loved one if they exhibit any of the following behaviors:
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They can’t focus attention or make eye contact.
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You can’t fully wake them up.
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They are mumbling or their speech doesn’t make sense.
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They are seeing or hearing things that aren’t there.
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They have become agitated without any obvious cause.
Is delirium preventable?
It’s a qualified maybe. Researchers say significant barriers, including under-recognition of the syndrome and poor understanding of the underlying disease process, have delayed the development of successful therapies. While delirium may reverse itself after hospital discharge, its effect on elderly patients may never fully subside, as this Harvard Health Watch article explains.
However, many hospitals throughout the U.S. and Canada are implementing the Hospital Elder Life Program (HELP). It’s a comprehensive, evidence-based program designed to provide optimal care and prevent delirium in hospitalized older patients. The HELP staff regularly assesses patients and supervised volunteers administer interventions that are modified daily based on symptoms and tracked for adherence. These may include a daily visitor program to improve orientation and communication, daily exercise and walking assistance, socialization, cognitive stimulation, assistance and companionship during meals, or hearing and vision adaptations.
As the Washington Post reported, helping older hospitalized patients minimize delirium by becoming mobile faster, and engaging them in communication for 30 minutes daily, resulted in faster discharge compared with patients that received standard post-surgical care.
Delirium remains underdiagnosed among older hospitalized patients. Recognizing the signs and addressing them is critical to successful outcomes.
Experts
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Sharon K. Inouye, M.D., M.P.H. professor of medicine, Harvard Medical School; director, Aging Brain Center, Institute for Aging Research, Hebrew Senior Life; 617-971-5390; agingbraincenter@hsl.harvard.edu
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Juebin Huang, M.D., Ph.D., assistant professor, Department of Neurology, Memory Impairment and Neurodegenerative Dementia (MIND) Center, University of Mississippi Medical Center. He authored the section on delirium for the Merck Manual; 601-984-5500 (main practice); 601-984-1100 (public affairs)
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The American Delirium Society is a professional cross-disciplinary organization focused on research, QI and education to improve delirium care.
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The Alzheimer’s Association has a Q&A on the differences between dementia and delirium.
Story ideas
- What protocols or programs are in place at local hospitals to address or minimize the incidence of delirium among older patients?
- What training (if any) is provided to hospital staff, and what education is given to families and patients before, during or after a hospital stay?
- How are local doctors and other health providers trained to recognize the differences between dementia and delirium? Are they?
