Diagnosing and Treating Delirium in Older Adults
This information on delirium is for health and mental health professionals including:
- psychiatrists
- psychotherapists
- physicians
- psychiatric nurses
- clinical social workers
This information is for reference only. Always consider the needs of individual patients and the setting in which the patient is located.
Prevelance
Risk Factors and Symptoms
Diagnosis
Management
Prevelance
Delirium (also called acute confusional state and acute brain syndrome) is a potentially life-threatening condition that occurs in 30% of older persons during medical hospitalization and in 10 to 50% of older adults during surgical hospitalization.
Also, up to 60% of residents in nursing homes may have delirium.
Mariano, C., Gould, E., Mezey, M., et al., (eds.). (1999). Best nursing practices in care for older adults: Incorporating essential gerontologic content into baccalaureate nursing education (2nd ed, Topic 6, p. 7). New York: The John A. Hartford Foundation Institute for Geriatric Nursing, Division of Nursing, School of Education, New York University.
David Meagher, Delirium: the role of psychiatry, Advances in Psychiatric Treatment (2001) 7: 433-442.
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Risk Factors and Symptoms
Factors related to illness:
CNS Illnesses
- Infections (e.g., meningitis, encephalitis)
- Seizures
- Stroke
- Subdural hematoma
- Tumors
General Illnesses
- Giant cell arteritis (a chronic inflammatory process involving the extracranial arteries)
- Hip fracture
- Hydrocephalus (increased fluid in the brain)
- Hypercapnia (reduced ventilation often associated with chronic obstructive pulmonary disease)
- Infection (e.g., UTI)
- Metabolic disturbances (e.g., liver or kidney failure, electrolyte disturbances, hyper- or hypoglycemia, diabetes, thyroid disorders)
- Myocardial infarction (heart attack)
- Tumors
Factors related to surgery:
Other factors:
- Dehydration
- Malnutrition
- Sudden environmental changes
- Depression
Negative outcomes associated with delirium
- Complications (such as pneumonia and decubitus ulcers) related to long-term hospital stays
- Seizures
- Coma
- Death
Symptoms of delirium
(may occur in any combination and may be intermittent)
- Altered awareness, disorientation, clouding of consciousness
- Impaired attention, concentration, and memory
- Inability to process visual and auditory stimuli
- Increased motor activity (e.g., restlessness, plucking, picking)
- Anxiety, suspicion, and agitation
- Misinterpretation, illusions, delusions, or hallucinations
- Speech abnormalities
- Reduced wakefulness; sleep disturbance
Other potential causes of symptoms
- Bipolar illness
- Stressful situation (e.g., loss of a loved one, traumatic incident, major life transition such as retirement)
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Diagnosis
DSM-IV diagnostic criteria
A definitive diagnosis of delirium is based on the following criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV):
- Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention.
- Change in cognition (e.g., memory deficit, disorientation, language disturbance, and perceptual disturbance) that is not better accounted for by a pre-existing, established, or evolving dementia.
- Development over a short period of time (usually hours to days) and disturbance tends to fluctuate during the course of the day.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by (insert presumed cause here: for the subdivisions listed below, reasons include a medical condition, substance intoxication or withdrawal, multiple factors, or uncertain, respectively).
The DSM-IV classification subdivides delirium by etiology into delirium due to:
- general medical condition
- substance intoxication delirium;
- substance withdrawal delirium;
- delirium due to multiple etiologies; and
- delirium not otherwise specified.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Washington, DC, 1994.
Instruments for diagnosing delirium include:
More specialized assessments
Depending on the initial findings, some patients may require more extensive evaluation for:
- Medical problems
- Psychological issues
- Substance abuse
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Management
The American Psychiatric Association (1999) Practice Guidelines for the Treatment of Patients with Delirium (Washington, DC: APA) recommends that management should include:
- Coordination of care with other physicians
- Identification of the cause of delirium
- Interventions for acute conditions
- Treatment of related disorders
- Monitoring of the patient’s safety
- Assessment and monitoring of the patient s psychiatric status
- Assessment of the psychological and social characteristics of the patient and family
- Establishment and maintenance of alliances among caregivers
- Education about the illness
- Care for the patient after treatment for delirium
Management may also include:
Care for suicidal patients
- Refer patients who present safety risks to themselves or others to a hospital emergency department
Medication
Delirium, an alteration of mental status with an acute onset, can usually be reversed with medical treatment. Consider the patient’s age, coexisting medical and psychiatric illnesses, response to medications, and possible drug interactions.
“Antipsychotics (such as haloperidol) are effective in alleviating a range of delirium symptoms in patients with either hyperactive or hypoactive clinical profiles.” (Platt, MM, Breitbart, W, Smith, M, et al., Efficacy of neuroleptics for hypoactive delirium. J Neuropsychiatry Clin Neurosci. 1994 Winter; 6(1):66-7.) Benzodiazepines may be helpful for patients who cannot tolerate antipsychotic drugs.
Other medications
People with delirium may have coexisting symptoms that should be treated with medicine. For example, patients with mild to moderate anxiety may be given anxiolytics (e.g., lorazepam, clonazepam) to control restlessness and sleeplessness.
Psychotherapy
Immediately refer patients to a psychiatrist if they have delirium plus any of the following conditions:
- Depression
- Severe anxiety or anorexia
- Significant psychomotor agitation or retardation
- Psychosis or mania
- Suicidal or homicidal thinking
Consider referring patients to a psychiatrist if they have delirium plus any of the following disorders:
- Substance abuse
- Eating disorders
- Post-traumatic stress or abuse
- Obsessive compulsive disorder or personality disorders
Patients who recover from delirium may experience psychological problems including depression and post-traumatic stress disorder. Reassure the patient that the episode of delirium was discrete, not part of a long-term disorder. Encourage him or her to be aware of the risk factors for delirium and, in the future, to seek help for medical problems that may lead to another episode of delirium. (Schofield, I. A small exploratory study of the reaction of older people to an episode of delirium. J Adv Nurs. 1997 May;25(5):942-52.)
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