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‫‪Delirium in the Elderly‬‬
‫‪Dr.leila kashani‬‬
‫‪92/3/23‬‬
‫دستیار روانپزشکی دانشگاه علوم پزشکی تهران‬
‫بیمارستان روزبه‬
DEFINITION
Acute and clinically significant deficit in
cognition , attention or memory
 Impaired or altered perception , illusion
 Disturbances of circadian rhythms
 Acute change in mental status with a fluctuating
course
 Altered level of consciousness
 Behavioral disturbances

KEY FEATURES
Acute onset
 Inattention
 Disorganized thinking
 Altered level of consciousness
 Cognitive abnormalities (disorientation, language
difficulties, impairment in memory/learning)
 Perceptual disturbances (illusions, delusions,
hallucinations)
 Emotional disturbances (anxiety, fear, irritability,
anger, depression, euphoria)

OTHER NAMES
Acute confusional state
 Encephalitis - encephalopathy
 Acute brain failure
 Toxic metabolic state
 CNS toxicity
 Sun downing
 Organic brain syndrome
 Cerebral insufficiency

INCIDENCE AMONG ELDERLY PATIENTS IS
HIGH
1/3 of patients presenting to ER
 1/3 of inpatients aged 70+ on general med units
 Incidence ranges 5.1% to 52.2% after noncardiac
surgery

Highest rates after hip fracture ( 50 % ) and aortic
surgeries
 In ICU : 70 -87 %

DELIRIUM: INCREASED RISK OF…
Functional decline
 New nursing home placement
 Persistent cognitive decline:


18-22% of hospitalized elders with
complete resolution 6-12 months after
discharge
HOW TO DISTINGUISH
DELIRIUM FROM DEMENTIA

Features seen in both:






Disorientation
Memory impairment
Paranoia
Hallucinations
Emotional lability
Sleep-wake cycle reversal

Key features of delirium:
Acute onset
 Impaired attention
 Altered level of
consciousness

PRODROME

Patients may describe and/or manifest:





Decreased concentration
Irritability, restlessness, anxiety, depression
Hypersensitivity to light and sound
Perceptual disturbances
Sleep disturbance - daytime somnolence and nocturnal
agitation
Delirium may be the only
manifestation of life-threatening
illness in the elderly patient
DELIRIUM:PSYCHOMOTOR SUBTYPES
Hyperactive (most recognized)
↑ psychomotor activity (agitation, mood
labiality, refusal to cooperate, disruptive
behaviors, combativeness)
Hypoactive (under recognized)
↓ psychomotor activity (sluggish, lethargic,
withdrawn, apathy)
Mixed (highest risk for morbidity/mortality)
Fluctuating course
A MODEL OF DELIRIUM
A multifactorial syndrome that arises from an
interrelationship between:
 Predisposing factors a patient’s underlying
vulnerability
AND
 Precipitating factors noxious insults
PREDISPOSING FACTORS
I.E. BASELINE UNDERLYING VULNERABILITY

Baseline cognitive
impairment


25-31% of delirious
patients have underlying
dementia
Medical comorbidities:






Any medical illness
Infections
Toxins, including drugs
Substance withdrawal
Organ failure: heart, liver,
kidney, etc.
Metabolic

Primary brain disorders
Visual impairment
 Hearing impairment
 Functional impairment
 Depression
 Advanced age
 History of ETOH abuse
 Male gender

PRECIPITATING FACTORS
I.E. NOXIOUS INSULTS
Medications
 Bedrest
 Indwelling bladder
catheters
 Physical restraints
 Iatrogenic events
 Uncontrolled pain
 Fluid/electrolyte
abnormalities

Infections
 Medical illnesses
 Urinary retention and
fecal impaction
 ETOH/drug withdrawal
 Environmental influences

SOME DRUG CLASSES THAT ARE
ASSOCIATED WITH DELIRIUM

Medications with psychoactive effects:
3.9-fold increased risk
 2 or more meds: 4.5-fold

Sedative-hypnotics: 3.0 to 11.7-fold
 Narcotics: 2.5 to 2.7-fold
 Anticholinergic drugs: 4.5 to 11.7-fold
 Risk of delirium increases as number of meds
prescribed rises

PREVENTION=GOOD HOSPITAL CARE FOR THE
ELDERLY PATIENT
RISK FACTOR
INTERVENTION
Cognitive impairment
Orientation protocol, cognitively
stimulating activities 3x/day
Sleep deprivation
Nonpharmacologic protocol, noise
reduction, schedule adjustments
Immobility
Ambulation or active ROM
exercises; minimize equipment
Visual impairment
Glasses or magnifying lens,
adaptive equipment
Hearing impairment
Portable amplifying devices,
earwax disimpaction
Dehydration
Early recognition and volume
repletion
MANAGING CONFUSED BEHAVIORS:
APPROACH STRATEGIES
Introduce yourself at each encounter
Use touch as appropriate
Start with the “Soft Approach”
Smile
Warm demeanor
Pleasant voice tones
Go slow
Talk in short, simple sentences
Avoid correcting/confrontation
Appeal to the emotion and let the patient know you will keep
him/her safe
Be flexible in getting tasks accomplished
KEYS TO EFFECTIVE MANAGEMENT

Find and treat the underlying disease(s)
and contributing factors
Comprehensive history and physical
 Including neurological and mental
status exams
 Choose lab tests and imaging studies
based on the above
 Review medication list
(Psychotropics, narcotics,
anticholinergics ,Digoxin, prednisone,
furosemide, cimetidine have
anticholinergic properties.)

CBC, electrolytes, BUN, Cr, glucose, LFTs, albumin
 O2 Saturation
 Urinalysis
 TSH, B12
 ? Toxin screen
 CXR
 CNS imaging remains debatable.
 LP in febrile patient with meningeal signs
 Cause not identified in 15 to 25%

DIAGNOSIS
History from family and/or caregivers
 Bedside observations
 DSM-IV diagnostic criteria


Diagnostic errors are common in:
Hypoactive form
 The setting of rapid fluctuations of cognition.

DIFFERENTIAL DIAGNOSIS

Dementia


Alzheimer dementia
Functional psychiatric disorders – delusional
psychosis or depressive states
Misdiagnosed as depression in as many as 40% of cases
 Schizophrenia has a more chronic hx with highly
systematized delusions.

TREATMENT OF DELIRIUM
 Treatment
of underlying
disorder will usually resolve in
rapid improvement of delirium
 The
diagnosis of delirium may
serve as a marker for future
cognitive and functional decline
ALWAYS TRY NONPHARMACOLOGIC
MEASURES FIRST
Presence of family members
 Interpersonal contact and reorientation (Provide clocks,
calendars )and environmental support
 Provide visual and hearing aids
 Remove indwelling devices: i.e. Foley catheters
 Mobilize patient
 A quiet environment with low-level lighting
 Uninterrupted sleep

Reduce noise levels.
 Minimize room changes in the hospital

MANAGEMENT: HYPERACTIVE, AGITATED
DELIRIUM
Use drugs only if absolutely necessary: harm,
interruption of medical care
 First line agent: haloperidol (IV, IM, or PO)


For mild delirium:
Oral dose: 0.25-0.5 mg
 IV/IM dose: 0.125-0.25 mg


For severe delirium: 0.5-1 mg IV/IM repeated q30
min until calm

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Patient will likely need 2-5 mg total as a loading dose
Maintenance dose :loading dose divided BID
May use quetiapine and risperidone ,…
WHAT ABOUT LORAZEPAM?
 Second
line agent
 Reserve for:
Sedative and ETOH withdrawal
 Neuroleptic Malignant Syndrome

SUMMARY OF KEY POINTS

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Evaluation should focus on ruling out infection,
medication toxicity, neurological events, metabolic
abnormalities, and new cardiorespiratory problems.
Prevention is the best therapy – focus on interpersonal
and environmental support.
antipsychotics and benzodiazepines are useful in
symptom control.
TAKE HOME POINTS: DELIRIUM IN THE
ELDERLY
A multifactorial syndrome: predisposing
vulnerability and precipitating insults
 Prevention should be our goal
 If delirium occurs, treat the underlying causes
 Always try nonpharmacologic approaches
 Use low dose antipsychotics in severe cases


thanks and any Questions?