Understanding Delirium in the Hospitalized Older Adult

[Kim Valentine]

The percentage of adults over age 65 in the United States is now more than 16% of the population. Because this age group tends to have more comorbid and chronic conditions, they are twice as likely to be hospitalized as compared to people under the age of 65.  Delirium is a recognized complication of hospital admissions for the older adult and carries a high risk of morbidity, so identification and treatment are vital to better outcomes.¹

Delirium in older adults is a medical emergency and can be misdiagnosed in a busy acute care setting. Of all adults over age 65 admitted to the hospital, 30% will develop delirium or acute confusion².  A delay in identification and treatment increases the likelihood of the patient developing severe complications, coma and possibly death.  Research shows that of all the patients in hospital with delirium, 35 to 40% will die within 1 year of complications associated with that episode of delirium.³ As nurses, we must be alert to the signs of delirium in our patients and advocate for prompt treatment of the cause.

What are the questions we need to ask ourselves as nurses to understand delirium?

Who is most at risk of developing delirium in the acute care setting?

• Older adults over age 65
• Patients with a pre-existing dementia or depression
• Older adults with multiple comorbidities 
• Patients with drug and or alcohol addictions

What are some of the possible causes of delirium?

• Urinary tract infection
• Respiratory infection
• Constipation
• Dehydration
• Hyponatremia or other metabolic imbalances
• Pain 
• Malnutrition
• Medical procedures (post-operative)
• Alcohol or drug withdrawal
• Sleep deprivation

Where in the acute care setting are patients at most risk?

• Critical care units
• Emergency Department
• Recovery room
• Any treatment area where there is a high level of sensory stimulation

How does delirium present?

• Poor concentration
• Disorientation to time and place
• Difficulty speaking
• Auditory or visual hallucinations
• Slowed movements or sleepiness (psychomotor retardation) as in hypoactive delirium
• Disturbed sleep habits and calling out
• Reversed sleep-wake cycle 
• Withdrawn and quiet
• Behavioral changes 
• Restlessness and agitation
• Combative behavior

Delirium vs Dementia

When a patient presents as "confused" in the hospital setting, the clinician may conclude the patient has dementia, however, a new presentation of confusion may very well be delirium.  

Dementia is a progressive decline in cognition and function

Example: Mom has been slowly, over time having problems with her short-term memory. It seems now that she can't seem to remember the steps to baking that apple pie she used to create with ease.

Delirium has an acute onset and a fluctuating course; sometimes described as a "waxing and waning"

Example: Mom seemed fine in the morning but by the afternoon she was talking to her deceased husband.  Then in the evening, Mom is back to her baseline.  Mom may be fine one day and confused the next.  

A fluctuating course is a primary feature of delirium. Therefore, a screening tool such as the Confusion Assessment Method or "CAM"⁴ should be conducted at least every shift. A CAM will properly identify this variable course so an underlying source may be investigated. Once identified, an appropriate treatment can be introduced.  Even when treatment is completed, delirium may not be cleared immediately.  There have been cases where delirium takes weeks (and even months) to clear.

Important points to consider include

• A severe case of delirium may worsen an already existing dementia.  
• Multiple episodes of delirium will be detrimental to cognition as a repeated assault on the brain. 
• A screening assessment for dementia such as a Montreal Cognitive Assessment should never be conducted during an episode of delirium.

As nurses, we are primary caregivers for our patients while they are in the hospital, so advocacy for appropriate treatment is especially vital.  The older adult patient presenting with symptoms of delirium may have a reversible condition, so prompt management may be the difference between life and debilitating complications or even death. Knowledge is power!

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References/Resources

¹Persons with hospital stays in the past year, by selected characteristics: United States, selected years 1997–2018

² Abrupt change in mental status

³ Delirium

⁴ Assessing and Managing Delirium in Older Adults with Dementia

Older Americans: Key Indicators of Well-Being

Delirium: Overview

Delirium

[Wuzzie]

Managing delirium in the hospital setting presents its challenges but managing it at home is a nightmare. I’m dealing with this right now. My mother swings from perfectly normal to confused, paranoid and down right mean. You never know when the switch is going to happen. Trying to find an appropriate living situation is nearly impossible. Memory Care is needed for when she is having an episode but totally inappropriate for when she is at her baseline. Assisted living is fine until the confusion hits requiring 24 hour in-person monitoring even though she goes days without an episode and they sometimes only last 20 minutes.  Who can afford that? What’s worse is when we seek help we are patted on the head and told its dementia. But it isn’t dementia. Dementia doesn’t wax and wane 180 degrees. She has had every test imaginable. CTs, EEGs, MRIs, ECGs, US blood flow studies, labs. She does have NASH with hepatic encephalopathy and is on Lactulose to maintain her ammonia levels but repeat EEGs with normal labs showed resolution of the encephalopathy yet here we are on the crazy rollercoaster.  We. Are. Exhausted. 
 

Also, 83 year old with mobility issues and TID laxatives is super fun. 

[Kitiger, RN]

31 minutes ago, Wuzzie said:

Managing delirium in the hospital setting presents its challenges but managing it at home is a nightmare. I’m dealing with this right now. My mother swings from perfectly normal to confused, paranoid and down right mean. You never know when the switch is going to happen. Trying to find an appropriate living situation is nearly impossible. Memory Care is needed for when she is having an episode but totally inappropriate for when she is at her baseline. Assisted living is fine until the confusion hits requiring 24 hour in-person monitoring even though she goes days without an episode and they sometimes only last 20 minutes.  Who can afford that? What’s worse is when we seek help we are patted on the head and told its dementia. But it isn’t dementia. Dementia doesn’t wax and wane 180 degrees. She has had every test imaginable. CTs, EEGs, MRIs, ECGs, US blood flow studies, labs. She does have NASH with hepatic encephalopathy and is on Lactulose to maintain her ammonia levels but repeat EEGs with normal labs showed resolution of the encephalopathy yet here we are on the crazy rollercoaster.  We. Are. Exhausted. 

Also, 83 year old with mobility issues and TID laxatives is super fun. 

It sounds like a nightmare. I respect you for doing what you can to help her. I would be exhausted, too. 

I assume you have pulled in what help you can get through Senior Services, etc.?

[Kitiger, RN]

Our NICU is very good at grouping care so as to allow the little ones to sleep. They also do what they can to decrease excess stimulation from other areas of the room.

Are adult ICUs doing the same?

[Catherine Johnston, BSN, RN]

I am surprised at the one year morbidity rate. It is higher than a hip fracture which is 25%. 

[JBMmom, MSN, NP]

4 hours ago, Wuzzie said:

We. Are. Exhausted. 

I am so sorry to read what you're dealing with. I can only imagine how difficult the situation is for all of you. You're right that people are so quick to blame dementia just because people are older and it's not the right thing for patients. I'm sure that if there were something obvious that could help, your family already would have found it. I hope that something changes for all of you!

[Kim Valentine, BSN, RN]

12 hours ago, Wuzzie said:

Managing delirium in the hospital setting presents its challenges but managing it at home is a nightmare. I’m dealing with this right now. My mother swings from perfectly normal to confused, paranoid and down right mean. You never know when the switch is going to happen. Trying to find an appropriate living situation is nearly impossible. Memory Care is needed for when she is having an episode but totally inappropriate for when she is at her baseline. Assisted living is fine until the confusion hits requiring 24 hour in-person monitoring even though she goes days without an episode and they sometimes only last 20 minutes.  Who can afford that? What’s worse is when we seek help we are patted on the head and told its dementia. But it isn’t dementia. Dementia doesn’t wax and wane 180 degrees. She has had every test imaginable. CTs, EEGs, MRIs, ECGs, US blood flow studies, labs. She does have NASH with hepatic encephalopathy and is on Lactulose to maintain her ammonia levels but repeat EEGs with normal labs showed resolution of the encephalopathy yet here we are on the crazy rollercoaster.  We. Are. Exhausted. 
 

Also, 83 year old with mobility issues and TID laxatives is super fun. 

Oh my goodness Wuzzie, my heart goes out to you.  I used to work in the community and this has to be one of the most difficult situations as a caregiver.  It sounds like she has had several tests. Is she followed by a geriatrician as well? I'm sure NASH complicates this too. I'm in Canada so not sure what the supports are like where you live, but I hope you are able to get some respite.  

[Susie2310]

In addition to the list of possible causes of delirium provided by the OP and others, I understand the following can also be causes/contributing factors: polypharmacy; certain medications; opiates; hypoxia; kidney failure; hypoglycemia; sepsis; anemia; and traumatic brain injury including acute ischemic or hemorrhagic stroke.  

It's so important to not just assume that the symptoms of delirium are the patient's normal baseline or that they are due to a particular cause without using a validated screening tool such as the CAM, doing a proper assessment, which can include how well the patient has been sleeping and resting; diagnostic testing (which can include MRI/CT/MRA/CXR); labs; along with a review of medications that have been administered/withheld and that the patient takes at home.  Looking for reversible causes and treatable causes is critically important. 

[Rita June Jarvis Isaac]

Interesting topic, I have seen patients with dementia as a result of the medication taken as well as the change in environment. Someone close to me experienced Steroid-induced Psychosis. She was on high doses of corticosteroid for a late-onset asthma condition. She was confused and had insomnia until the medication had to be discontinued. Sometimes choosing one path over the other is difficult when the medication you need causes other complications. Unfortunately, she passed a few days later.