Understanding Delirium in the Hospitalized Older Adult
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.
NursesGeneral NursingKnowledge
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!
