Delirium

DELIRIUM IN OLDER ADULTS
DR.BUSHRA RANI
DPT(SMC)
MS(RIU)
DELIRIUM INCIDENCE
• 10-24 percent of the hospital patient population
• Incidence increases with patient complexity
• 60 percent occurs in older adult patients
• 60-80 percent incidence in those admitted to a Medical ICU
• 80-90 percent in older adults with terminal cancer.
DELIRIUM OR ACUTE
CONFUSIONAL STATE DEFINITION
• Syndrome
• Acute Brain Failure
• Characterized by:
• Acute
• Disturbance in consciousness
• Reduced ability to focus, sustain or shift attention
• Occur over short period of time
• Fluctuates over the course of a day
ETIOLOGY
• Potential causes of delirium include:
o Inadequate pain control
o Drug or toxin
o Metabolic disorders
o Neurovascular insult
o Systemic organ failure
o Complications from a systemic disease
FIGURE OUT THE TRIGGER
Drug use (hypnotics, anticholinergic) (30%)
Electrolyte abnormalities (40%)
Lack of drugs (withdrawal)
Infection (40%)
Reduced sensory input (24%)
Intracranial problems (stroke)
Urinary retention and fecal impaction
Myocardial or metabolic problems (14- 26%)
Often combination of several of the above.

Francis J, Martin D, Kapoor W: A prospective study of delirium in hospitalized elderly. J Am Med Assoc. 263:1097-1101 1990
Increased mortality DELIRIUM
Poorer functional status
Limited rehabilitation
Increased hospital-acquired complications
Prolonged hospital stay
Increased risk of institutionalization
Higher health care expenditures.
DIFFERENTIAL
DIAGNOSIS
• Hypoactive Delirium
• Hyperactive Delirium
• Mixed Delirium (46%)
• **The main feature differentiating delirium from depression from

dementia:
Acute – fluctuating nature of symptoms
DELIRIUM DIFFERENTIAL
DIAGNOSIS
Depression Delirium Dementia
Onset Weeks to months Hours to days Months to years
Mood Low Apathetic Fluctuates Fluctuates
Course Chronic, Responds Acute, responds to Chronic, with
to treatment treatment deterioration over time.
Self- Likely to be Maybe aware of Hide or be unaware of
awareness concerned about changing cognition memory
memory
ADLs May neglect basic Intact or impaired Intact early, impaired
self-care as disease progresses
IADLs Intact or impaired Intact or impaired Intact early, impaired
before ADLs as disease
progresses
Sarutzki-Tucker & Ferry, 2014
CLINICAL PRESENTATION
• Clinical manifestations appear over a shorter period of time (few
days)
• Progressive decline in memory, awareness to surroundings or
behavior
• Fluctuate throughout the day
• Inability to maintain normal sequential thought
PATHOPHYSIOLOGY
• Pathophysiology is unclear
• Widespread derangement of cerebral metabolism or
cerebral insufficiency that leads to decreased synthesis
of cerebral neurotransmitters, especially acetylcholine.
• Brain maladaptive reaction to acute stress (Ham et al,
2014)
• The core group of clinical manifestations:
• Attention deficits
• Sleep-wake cycle disturbance
• Motor activity changes
• May present as psychosis, mood changes, fluctuating LOCs,
disorientation, memory impairment, and disturbances in
speech and language.
MORTALITY
• Delirium is a medical emergency
• Persons who have delirium have a statistically significant higher risk
of death compared to age cohorts who do not.
MEDICATION HIERARCHY
Level One - Neuroleptics
• Level 1 - Neuroleptic Level 2 -
Level Two – Analgesics; Sedatives-Hypnotics; Dopamine agonists
• Level 3
Level Three – Antihistamine; anti-inflammatory;
anticholinergic; antidepressants; cardiac glycosides
Level Four – H2 Antagonist, Dihydropyridine;

Tricyclic antidepressants; anti-Parkinson;
antimicrobials
Score 3- High ACA Score 2 – Moderate Score 1 – Mild ACA
ACA
Amitriptyline Amantadine Alprazolam
Atropine Belladonna Atenolol
Clozapine Carbamazepine Bupropion
ANTICHOLIN Darifenacin Cyclobenzaprine Captopril
GERGIC
Desipramine Cyproheptadine Chlorthalidone
MEDICATIONS
Diphenhydramine Loxapine Cimetidine
Play a major role in Doxepin Meperidine Clorazepte

delirium Hydroxyzine Methotrimeprazine Codeine
development
Imipramine Molindone Colchicine
Cumulative Nortriptyline Oxcarbazepine Diazepam
anticholinergic
burden Olanzapine Pimozide Digoxin
Oxybutynin Fentanyl
Paroxetine Furosemide
**ACA=
anticholinergic Quetiapine Haloperidol
activity Tolterodine Metoprolol
Imipramine Prednisone
SCREENING TOOLS
• Richmond Agitation Sedation Scale (RASS)
• Confusion Assessment Method (CAM)
• Confusion Assessment Method for ICU (CAM-ICU)
• Neelon and Champagne Confusion Scale (NEECHAM)
E. Wesley Ely, MD MPH and Vanderbilt University, 2002.
CONFUSIONAL ASSESSMENT METHOD (CAM)
DELIRIUM IF YOU HAVE 1 + 2 +[EITHER 3 OR 4].
Diagnostic Features Definitions and Characteristics
1. Acute Onset • Is there evidence of an acute change in mental status from

Fluctuating Course baseline?
• Did the abnormal behavior fluctuate during the day, does it come
and go, or increase and decrease in severity?
2. Inattention • Did the patient have difficulty focusing attention (easily

distracted) or have difficulty keeping track or what was being
said?
3. Disorganized • Was the patient’s thinking disorganized or incoherent, e.g.

Thinking rambling, irrelevant conversation, unclear or illogical flow of
ideas, or unpredictable switching from subject to subject?
4. Altered LOC • LOC – alert (normal), vigilant (hyper alert), lethargic (drowsy
but easily arousable), stupor (difficulty to arouse) or coma
(unarousable)
Inouye SK, vanDyck CH, Alessi CA, et al. Clarifying confusion: The Confusion Assessment Method. A new
method for detection of delirium. Ann Intern Med 1990:113:941-8.
DELIRIUM
MANAGEMENT LISTICAL
• Knowledge and addressing the underlying cause
• Be mindful of the environment
• Do not over stimulate
• Good patient care
• Medications (hopefully last resort)
Assessment
Vital Signs: BP, P, HR, T, Pulse Ox, Pain
Physical Examination
Urinalysis
Cr, Na, K, Ca, Glucose
CBC with differential
Review old and new anticholinergic medications
Review old and new sedating medications
Review the need for Foley catheters, IV lines, and
other tethers
Apply glasses, insert hearing aides
INTERVENTION STEP 1
• Identify and Treat reversible contributors
• Medications
• Infection
• Fluid balance disorders
• Impaired CNS oxygenation
• Severe pain
• Sensory deprivation
• Elimination Problems
INTERVENTION STEP 2
• Maintain behavioral control
• Behavioral interventions
• Pharmacologic Interventions
• Necessary for behavior that is dangerous to patient or others and does
not respond to other management strategies
INTERVENTION 3
• Anticipate and prevent or manage complications
• Urinary incontinence
• Immobility and falls
• Pressure ulcers
• Sleep disturbance
• Feeding disorders
INTERVENTION 4
• Restore function in delirious patients
• Hospital environment
• Cognitive reconditioning
• Ability to perform ADL
• Family education/support/ participation
• Discharge
PREVENTION
• Limit use of medications known to cause delirium
• Ensure good nutrition and hydration
• Correct sensory deprivation
• Encourage normal sleep patterns
• Promote cognitive stimulation
PROGNOSIS
• Delirium is usually reversible.
• Take several weeks for mental function to return to normal levels
• The longer the delirium goes untreated – there is worsening global
cognition and executive function worsening.
• Pathophysiological evidence – inflammation – neuronal apoptosis
– brain atrophy
REFERENCES
• Catic AG. Identification and management of in-hospital drug-
induced delirium in older patients. Drugs Aging. 2011:28(9):737-
748.
• Clegg A, Young JB. Which medications to avoid in people at risk of
delirium: a systematic review. Age and Ageing. 2011. 40:23-29.
• Gatewood M. Managing delirium among elderly patients in the ED.
Physician’s Weekly, 2013.
• Maldonado JR. Delirium in the acute care setting: characteristics,
diagnosis and treatment. Critical Care Clinics. 2008;24:657-722.
• Reade MC, Finfer S. Sedation and delirium in the intensive care unit.
New England Journal of Medicine 2014;370(5):444-454.
• Sarutzki-Tucker A, Ferry R. Beware of delirium. The Journal for
Nurse Practitioners 2014:10(8); 575-581.

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DELIRIUM IN OLDER ADULTS

Often combination of several of the above.

• **The main feature differentiating delirium from depression from

Level Four – H2 Antagonist, Dihydropyridine;

Play a major role in Doxepin Meperidine Clorazepte

1. Acute Onset • Is there evidence of an acute change in mental status from

2. Inattention • Did the patient have difficulty focusing attention (easily

3. Disorganized • Was the patient’s thinking disorganized or incoherent, e.g.

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