What is Delirium?
Delirium is not a mental illness. It is a medical condition that causes a temporary problem with mental function. Another way to describe delirium is sudden, acute confusion.
In the elderly, sudden confusion/delirium is a medical emergency, and is often the presenting symptom of another underlying illness. Early diagnosis and treatment offer the best chance of recovery.
The symptoms of delirium are often attributed to other illnesses or aging, particularly in older adults with underlying dementia. However, it is important to remember that delirium is distinct from dementia in that the elderly adult’s thinking abilities change quickly, often with no warning. People with dementia will often experience delirium, and it can worsen their dementia symptoms.
Sudden confusion in the elderly is commonly overlooked in today’s busy health care settings, but it has serious consequences for their health, function, and discharge disposition. The questions and answers in this section will help you learn more about how to prevent, recognize, and treat delirium in older Veterans.
What are Risk Factors for Delirium?
No single cause of acute confusion/delirium has been identified. However, a recent systematic review and meta-analysis of delirium risk factors by the United Kingdom National Institute for Health and Clinical Excellence (NICE) identified six independent factors associated with delirium risk:
When your elderly patients have any of the conditions listed above, you should consider them at risk for developing delirium. If more than one condition is present, the patient should be screened for delirium.
Other medical conditions that can increase risk of delirium include:
The risk of delirium has been described as the interaction of predisposing and precipitating factors. When elderly patients have many or severe predisposing factors, they may develop delirium in the presence of relatively benign precipitating factors. When patients have few predisposing factors, several severe precipitating factors may occur before delirium develops.
Tools you can use to assess delirium risk:
Who Should be Screened for Delirium?
Based on available evidence, senior or hospitalized Veterans should not be routinely screened for acute confusion/delirium. However, screening is indicated for patients who are at risk. The presentation of delirium may fall into one of three classifications below:
Many valid, reliable screening instruments are available to help you screen for delirium in at-risk Veterans across clinical settings. Choose an instrument that fits your particular clinical setting to make routine use and follow-up easier:
For patients in intensive care, two alternative assessments are available:
How is Delirium Diagnosed?
Acute confusion/delirium is a sign that the brain is not functioning in a normal way. Its acute onset and fluctuating course distinguish it from dementia.
If you suspect an elderly Veteran has delirium, you should complete a comprehensive history, physical examination, and targeted laboratory testing. Multiple contributing factors are often present, so the diagnostic evaluation should continue beyond a single "cause" being identified.
The history should focus on the time sequence of changes in mental status and any possible link with other symptoms or events. Medications are the most common and treatable cause of delirium, so a complete medication history is imperative. In the outpatient setting, it is also important to review the patient's use of OTC drugs, alcohol, and herbal or other supplements.
The physical examination should include a careful general medical examination, with a complete neurologic and mental status examination. The goal is to identifying acute medical issues or exacerbations of chronic medical problems that might be contributing to delirium.
Laboratory tests should be selected based on history and examination findings. Most patients require a CBC, electrolytes, and renal function tests. Cerebral imaging is rarely helpful, except in cases of head trauma or new focal neurologic findings. Tests that may be indicated include:
It is important to search for all potential causes or symptoms and treat underlying causes as aggressively as possible. Most common causes of delirium include:
How is Delirium Treated?
After diagnosing and identifying the underlying causes of delirium, prompt treatment is the key to resolving delirium as quickly as possible. With prompt treatment, most elderly patients will have a gradual return of previous cognitive function.
Treatment includes behavioral interventions and judicious use of pharmacologic agents, with a focus on treating the reversible conditions, optimizing sensory input, and restoring function. If necessary, low doses of high-potency antipsychotics may be helpful, but only for as long as needed to manage acute delirium symptoms.
Behavioral interventions will include calm communication with reorientation only as needed. Staff should make every effort to tolerate behaviors that do not threaten the safety of the patient or others, anticipate what the patient may need, and try not to agitate them. Restraints should not be used, as they are known to further agitate delirious individuals.
Try to anticipate and address potential complications by:
Involve the family to the extent possible by explaining the nature of delirium and what to expect as the condition clears. Ask them to watch for changes in the patient’s alertness and cognition and to call for help if the delirium worsens.
The videos below provide specific strategies to help you manage delirium in the elderly:
What Will Help Prevent Delirium?
Preventing acute confusion/delirium in the elderly is much easier than treating it. While we do not have a definitive way to prevent delirium, using universal precautions helps keep seniors alert, attentive, and engaged in their environment. For example, families and staff can help to ensure that older adults at risk for confusion get adequate sleep and have the support they need.
Risk for delirium increases in the elderly with cognitive and/or sensory impairments, and in those who are sleep deprived. Families at home or staff in the hospital can help avoid these problems by:
Additional strategies for hospital staff include:
Veterans Crisis Line:
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U.S. Department of Veterans Affairs | 810 Vermont Avenue, NW Washington DC 20420
Last updated March 12, 2014