An 80-year-old woman has been admitted to your ward after an episode of a fall. She seems to be loudly talking to herself, but it is incomprehensible. She has an anxious demeanour and repeatedly pulls at her bedclothes. She argues with the nursing staff and has angrily refused to have a blood sample taken.
A 74-year-old gentleman is recovering from a heart attack and wants to rest in the bed. He is polite and sleepy, and he is not interested in eating or drinking. Sometimes his speech is incoherent and he doesn’t seem to follow what is said to him.
Delirium is a much common life-threatening, preventable condition in older adults. About 60% of delirium goes undiagnosed. About 30% of the older adults admitted to the general ward and 15% of the older adults visiting the emergency room have delirium. The incidence goes up to 50% after major hip surgery, and 25% after any major surgical procedures. One-fourth of the patients have hyperactive delirium and the rest of them are hypoactive, which are poorly recognized henceforth the prognosis is also poor. The concept of delirium as an acute one is gone as the recognition of persisting delirium in 45% of patients after hospital discharge and 33% at 1 month of recovering from the acute episode. Risk factors for the persistence of delirium include advanced age, dementia, multiple coexisting chronic medical conditions, and the use of physical restraints. Delirium results in increased mortality, hospitalization, increased length of stay in hospital and, poor and/or worsening cognition.
Risk factors for delirium are old age (over 65 years), frailty, the severity of the illness, multiple chronic medical conditions, dementia, admission to hospital with infection or dehydration, visual and hearing impairment, polypharmacy, excessive alcohol intake, renal impairment, and malnutrition.
Causes of delirium can be remembered by the mnemonic DELIRIUM. D for Drugs (arising from increasing the doses of drugs or by adverse drug reactions), E for Electrolyte disturbances, L for Lack of drugs (poor pain control, alcohol withdrawal and sedatives withdrawal), I for Infections (UTI, LRTI, and soft tissue infections), R for Reduced sensory input (poor hearing and vision), I for Intracranial disease (stroke, hemorrhage, and infections), U for Urinary retention and fecal impaction, M for Myocardial, and pulmonary disease like MI, Acute exacerbation COPD etc.,
Diagnosis of delirium is clinical. Key diagnostic features include acute onset and fluctuating course, inattention, impaired level of consciousness, and cognitive disturbances. Other supportive features are altered sleep-wake cycle, hallucinations or illusions, delusions, psychomotor disturbance, inappropriate behaviour and emotional liability.
Confusion assessment method (CAM):
Diagnosis of delirium requires Features 1 and 2, and either of 3 or 4.
4AT is another tool that doesn’t need any special training and takes less than 2 minutes to access the patient. It holds a maximum score of 12, and a delirium diagnosis needs a score of more than 4.
Primary prevention with a multicomponent approach is the best strategy to prevent delirium. Non-pharmacologic approaches are
Pharmacologic strategies should be reserved only for patients who are at harm to themselves or others and in severely agitated patients. Haloperidol, Risperidone, Quetiapine are some of the antipsychotic medications used. They should be used in the lowest possible dose for the shortest possible duration. The common adverse events associated with are EPS, QT prolongation, and increased sedation. Evidence for melatonin and its analogs as well as for ramelteon are inconclusive.
Delirium is more common and is hazardous to older adults. Early recognition and appropriate measures will improve the outcomes in older adults. Delirium is one of the risk factors for developing dementia and vice versa.
Dr Manicka Saravanan S, Consultant Geriatric Medicine Kauvery Hospital Chennai
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