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Delirium in older people

This booklet is about delirium, a term used to describe changes to thinking and behaviour that occur over a very short time.

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ISBN: 0 642 82988 8, Online ISBN: 0 642 82989 6, Publications Approval Number: 3868,
Print Copyright © Commonwealth of Australia 2006, Online Copyright, © Commonwealth of Australia 2006.

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Using this booklet
Precis
Preface
About Delirium
Managing Delirium
Screening Tools (available via the PDF or by ordering the publication)
Glossary
References

Using this booklet

It needn’t be read from beginning to end. It is designed for health professionals and support workers who work with older people – to be dipped into when you see someone in care with sudden changes to their thinking or behaviour. It includes a glossary of less-familiar term and a reference list for people wishing to investigate delirium further.

The first section provides an overview of delirium, the current issues involved and descriptions of various presentations. The second and third sections look at issues in assessment and management, and present some tools that might be useful in identifying delirium.

However... this book is intended to provide advice on care. It should be used in conjunction with recent literature and drug information. It is not intended to replace good clinical judgement.

Prepared by Author: Stephen Harding
Project and Editorial Support by: Lynne Barnes and Eimear Muir-Cohrane.

Acknowledgements

Alzheimer’s Australia; Drug & Therapeutics Information Service (DATIS), Repatriation General Hospital, Daw Park (Adelaide), ACH Group; Aged Care Association, Australia; Aged & Community Services, Australia; Australian & New Mental Health Nurses Inc; Hammond Care Group; Royal College of Nursing, Australia for feedback on the manuscript; and Inprint Design for layout and design. Staff from Repatriation General Hospital, Daw Park (Adelaide), Cityviews Translational Care Unit (South Australia) and InHome West (community care) (South Australia) for feedback and participation in focus groups.

Precis

Delirium - or Acute Confusional State, as it is also known - is a reversible disorder of cognitive function. It is a common health problem for older people, with those in hospitals or residential care at particular risk. Defined as an acute disturbance of attention and cognition, it is under recognised by health professionals.

Research suggests delirium affects up to 56% of older people admitted to hospital. The syndrome has not been well studied in residential care, but what data is available suggests a rate at least as high as that found in acute settings.

Delirium can be precipitated by almost any medical condition or pharmacological treatment (and occasionally, apparently, nothing at all) and may be the only symptom of illness. Delirium can be difficult to recognise, as it does not have a single, clear presentation, a problem further compounded by difficulties in identifying risks for delirium and a lack of agreement about what core risk factors are. Levkoff et al. identified ageing, dementia, sensory impairment, ill-health and institutional care as the most significant risk factors. Inouye and Charpentier have identified the following factors as contributing significantly to the risk of developing a delirium: use of physical restraints, malnutrition, more than three medications, presence of indwelling bladder catheter, and ‘any iatrogenic event’. Sleep deprivation, sensory impairment, existing cognitive impairment, poor hydration/nutritional status and immobility are also seen as risk factors.

Although delirium can have a short duration, to describe it as a transient disorder is to ignore the reality that symptoms may persist for months. This can have dire consequences for the function and health of the patient. It commonly leads to hospitalisation (contributing to extended lengths of stay) and increased morbidity/mortality. It is also predictive of physical, functional and cognitive decline, leading to a decline in independence and a need for a higher level of care. It is important that delirium is recognised early or, better still, if those at risk can be identified, before it develops.Top of page

Preface

The gradual deterioration in function with increasing age is so widely perceived and so expected that all decline in an older person tends to be attributed to age.

It is illogical to say, cats have four legs, dogs have four legs, therefore cats are dogs. However, one sees clinicians apparently reasoning along similar lines – many older people are confused, an old person is confused, they must be confused because they are old.

If a person is told by their medical practitioner that their kidneys are failing a series of questions will quickly follow: ‘Why have they failed? How long has this been going on? What does the future hold? What can you do about the problem? Can you cure things?’ Delirium is an acute confusional state of the brain. It is essentially acute ‘brain failure’.

Our brains are more important than our kidneys. They cannot be replaced or their function replicated by an external device. Delirium should be taken as a challenge to a thinking health professional. It requires answers as much as failed renal systems do.

An adequate history is the first step. The patient cannot supply one. A collateral history must be sought from another close observer. The duration of the delirium is the key piece of information.

Delirium runs its course over days and weeks; dementia over many months – more usually years. The challenge increases when one notes that delirium commonly supervenes in a person with reduced cerebral reserves (e.g. the very old, or those with pre-existing dementia or chronic brain failure). The clinician then has to know when delirium begins to overlay previously noted symptoms of dementia. Delirium is essentially a thinking and attention deficit disorder. The clinician should note that in delirium, the patient cannot hold to a theme in conversation, even if it is based on old retained memories. The patient is easily distracted by external stimuli or diverted by their non-sequential thinking into rapid changes of idea and theme.

A dementia patient, even when advanced in their disease, will often give delight to their listener as they tell of past life events, even though with a few distortions of truth. One feels one has made a contact. In delirium, one should appreciate early on that the patient is as if in the next room, half hearing, half attending. And prone to move on to new themes, often with language that is deranged in structure and form.

A clinician can recognise more easily the agitated restless victim of delirium. Overlooked – with consequent risk to life and safety – is the older person who is quietly delirious, sitting listless and unnoticed. Brain failure or delirium needs the best of health care and diagnostic effort.

A delirious patient can exhibit evidence of problems ranging from electrolyte derangements or adverse drug effects, to occult infection, or less commonly a disorder of the brain itself. There is an old adage that if a person under statutory old age (say 65) is delirious, the answer more often lies in the brain (e.g. encephalitis, meningitis), while for the older person above 65, the answer lies outside the brain (e.g. infection, biochemical derangement). This book draws on the best of recent literature, pointing out that outcomes can be improved and delirium prevented by competent and quality nursing of the older potentially delirious patient. Drugs are not the routine answer, as they are a force for both good and evil. They can compromise the care of the delirious, adding to confusion, and reducing mobility and cooperation with food and fluid intake.

Past generations of gerontic nurses knew that dehydration and constipation commonly went together in those with dementia. If severe, delirium was an anticipated event to complete the triad.

I was always impressed with the senior nurse in the long stay ward who told me to check a patient in a certain bed because ‘they were a bit off’. The nurse was telling me in code that they had discovered delirium and my job was to identify the pneumonia or the urinary infection, and prescribe the appropriate new drug.

This text allows those working with older people to move away from coded conversations and toward a proper approach to life-threatening failure of a human organ.

As the US anti-ageist campaigner and advocate Maggie Kuhn once said ‘The most important organ in the human body is wrinkled at birth ... the brain!’

Philip Henschke

Geriatrician
Adelaide 2005Top of page

About Delirium

Introduction

Delirium is a clinical syndrome, rather than a disorder or disease in itself, and is frequently confused with other conditions. It describes a set of symptoms that impair cognitive and physical function and can lead to severe illness and possibly death.

Delirium is an acute medical condition, and should be treated as a medical emergency.

Prompt identification is important, as delirium may be the only indicator of the presence of a physical disorder.

Delirium rarely has a single cause. All potential causes should be investigated and risk factors addressed as part of appropriate management. It is however, often poorly recognised, and even when symptoms are recognised they are often misidentified and mistreated.

This section looks at the dynamics of delirium and the need for careful investigation and data gathering to accurately identify this clinical syndrome.

Possible precipitants of delirium in older people include:

• disease
• metabolic disorder
• carcinoma
• infection
• neurological disorder
• inflammation
• pain
• dehydration (and constipation)
• malnutrition
• urinary retention
• sensory impairment
• drug effects (and interactions)
• drug/alcohol withdrawal syndromes.

Diagnosis

In the Diagnostic and Statistical Manual of Mental Disorders (DSM)1 the American Psychiatric Association identifies three main criteria for the diagnosis of delirium:

1. rapid onset of symptoms and/or fluctuating sensorium
2. impairment of attention
3. change in cognitive function/development of perceptual disturbance.

Disorientation to time and place, and disturbance of the sleep/wake cycle are also common features. The presence of cognitive impairment means the likelihood of a diagnosis of dementia being made is high.

The lack of obvious significant physical illness in the face of apparent mental symptoms often leads clinicians to assume a diagnosis of a psychiatric disorder.47,59 The presence of perceptual disturbance can lead to an incorrect diagnosis of psychosis, the treatment of which will likely exacerbate the delirium.

Equally, a somnolent or withdrawn presentation may lead to diagnosis of, and treatment for, depression. The resultant administration of antidepressants with anticholinergic effects can also exacerbate the delirium.

The fluctuating nature of delirium, combined with cognitive decline and hallucinations, are suggestive of Lewy-Body Dementia. In addition to the cognitive features of a dementia, patients with Lewy-Body Dementia often suffer Parkinsonian features (particularly rigidity) – visual hallucinations, delusions and frequent unexplained falls are common. Changes in behaviour, alertness, and cognitive function can occur. These changes can be quite dramatic and include attentional deficits that may make Lewy-Body Dementia difficult to differentiate from delirium.

However, with most dementias the history will usually show a progressive decline over many months and years, rather than the more acute onset seen in delirium.

Delirium and dementia are not mutually exclusive, although it may be that the severity of cognitive impairment increases the risk of delirium. Equally, it is likely that symptoms of delirium will be missed or dismissed because of the presence of dementia.

This is not unreasonable, as dementia can produce similar symptoms (e.g. cognitive decline, fluctuating behaviour). Therefore, the existence of dementia should alert clinicians to the possibility of a delirium occurring.Top of page

Prevention

Primary prevention represents the most effective strategy for dealing with delirium.

Work by Inouye, Bogardus, Charpentier et al. suggests that identifying those at risk before they develop a delirium reduces the chance of a delirium developing, and may reduce the severity of a delirium should it occur (particularly for those with a moderate risk).

Marcantonio, Flacker, Wright et al. suggest that it is possible to not only reduce risk but also to reduce the incidence and severity of delirium by focussed interventions that address risk factors.

Mentes, looking at high care residential care populations, developed a nursing protocol focussing on the presence of risk factors, in order to reduce the incidence of delirium occurring.

Gathering Information

Delirium is recognised as an acute change in a person’s cognitive function, often accompanied by changes in behaviour. Rather than arising from a single cause, delirium often results from a number of contributing factors.

Identification of delirium is possible by drawing on information obtained from a history of recent changes in the health of a person and their circumstances. It is appropriate to assume delirium may be the cause of cognitive impairment, and to consider alternatives once it is excluded. If cognitive impairment is excluded, depression should be considered a possible cause and investigated, before considering dementia.

It is extremely important to gather a complete and accurate history, with corroboration from carers, to establish the onset and a recent history of symptoms – including effects on memory, behaviour, speech and function (including activities of daily living – ADLs).

Information gathered should include details about recent eating habits, management of medications, a list of current medications from all sources, and any other pertinent information.

Primary care practitioners may order blood and urine tests to rule out physical illness (e.g. CUE,
FBE, LFT, TFT, ESR, B12 and folate) and a chest x-ray, and from the results plan appropriate management.

Risk Factors

Inouye and Charpentier have identified the following risk factors for delirium: use of physical restraints, malnutrition, more than three drugs added in 24 hours, use of urinary catheter, iatrogenic events, cognitive impairment, sleep deprivation, immobility, visual and hearing impairment, and dehydration.

Major risk factors identified by others include ageing, sensory impairment, ill-health and institutional care.

Summary of Risk Factors

• large number of medications
• drug and alcohol use/misuse or withdrawal
• dehydration and poor nutrition
• hepatic or renal dysfunction
• electrolyte disturbance
• sensory impairment
• sleep deprivation
• existing cognitive impairment / brain damage
• pain
• respiratory/cardiovascular disease
• infection
• immobility.

Drugs

The drugs most commonly associated with the precipitation of delirium are psychotropics and opioids, but they are by no means the only groups of related drugs.

Any drug can precipitate a delirium, as the prescribing information of pharmacological agents indicates. Adverse effects are more common when new drugs are added to a regimen, and/or with higher doses, but can also occur with therapeutic doses at any time during therapy.

It is wise to consider legal and illegal drugs, as well as prescribed and over-the-counter agents, including herbal or complementary, as potential causes. The mnemonic proposed by Flaherty suggests almost all groups.Top of page

Acute Change in M[ental] S[tate]

Antiparkinsonian drugs
Cardiovascular drugs
Urinary incontinence drugs
Theophylline
Emptying (motility) drugs

Corticosteroids
H2 blockers
Antimicrobials
Narcotics
Geropsychiatry drugs
ENT drugs

Insomnia drugs
NSAIDS (including COX-2s)

Muscle relaxants

Seizure drugs

'Geropsychiatry' drugs include all psychotropics:

• major tranquillisers (e.g. haloperidol, pericyazine) – including the newer atypicals (e.g. olanzapine and risperidone)
• minor tranquillisers and sedatives (e.g. diazepam, clonazepam, nitrazepam); and
• antidepressants (e.g. amitriptyline, imipramine, fluoxetine, paroxetine).

Other psychotropics include lithium and the 'Seizure' drugs (antiepileptics) which are used as mood stabilisers. This group, including agents such as carbamazepine and sodium valproate, are increasingly used in the management of behavioural problems associated with dementia.

Psychotropics are commonly used in the management of delirium, but often cause or contribute to the delirium, so should be used with care.

Of the other groups, 'Urinary incontinence drugs' include ditropan and propantheline, while the 'Emptying drugs' include cisapride and metoclopramide. Theophylline is now little used, but other respiratory drugs (e.g. ipratropium – because of anticholinergic effects) and cortico-steroids are recognised precipitants of delirium.

The Australian Medicines Handbook Drug Choice Companion: Aged Care should be a standard reference for people working with older adults, used in conjunction with more comprehensive information provided in the Australian Medicines Handbook. The ‘Aged Care’ drug choice companion includes a summary of delirium and the drugs that might be implicated, as well as a list of drugs with significant anticholinergic effects (p186).

Presenting Features

The clinical picture in a developing delirium is often characterised by symptoms and behaviours not previously exhibited by a person, including:

• social withdrawal
• restlessness
• anxiety (or an increase in anxiety)
• irritability
• insomnia
• nightmares.

Identifying delirium early is very important.

Identification should be supported by obtaining additional information from those in frequent contact, such as family, friends or regular care staff. This is equally relevant for people with or without good verbal skills. As a person’s ability to describe symptoms declines so the need for good clinical judgement increases. Information from people who have had frequent, recent contact becomes vital. In all circumstances the history of change is critical.

The most important features of delirium are:

1. the speed with which symptoms develop;
2. the way symptoms tend to fluctuate; and
3. problems people have paying attention.

When speaking with the person they may:

• have problems naming people, objects
• be easily distracted
• be irritable and/or uncooperative
• be difficult to converse with due to poor attention abilities
• exhibit somnolence*
• exhibit hyperactivity*
• exhibit hypoactivity*

(*depending on type of delirium)

• exhibit poor concentration
• exhibit disorganised thinking
• exhibit delusional thinking (possibly paranoid)
• experience disturbed memory
• experience hallucinations (typically visual).

For a diagnosis of delirium these features may not be evident all the time, but must have recency, though they will fluctuate.

A person may describe episodes of confusion or reduced mental clarity, perhaps with associated anxiety. They could display language or behaviour ‘that is not like them’. People with reduced cognitive function and limited speech may exhibit anxiety or irritability that manifests atypically as resistiveness or withdrawal.

Carers and care staff may describe features such as an acute change or decline in function, including: fluctuating capacity; disturbed sleep/wake cycle or sleeplessness; fluctuating activity level over the day; rapid memory decline; episodic ‘confusion’ (particularly during the day) and a rapid change in personality or behaviour.

Specific Presenting Features

That delirium can present in a number of ways has been recognised for many years, with psychomotor activity the yardstick. Lipowski, for example, describes two main forms – hypoactive/hypoalert and hyperactive/hyperalert – as well as an alternating form. Similarly, Ross, Peyser, Shapiro et al. speak of activated and somnolent types.Top of page

Hypoactive

Lipowski’s 37 hypoactive/hypoalert form accounts for perhaps 20% of cases.35 Also described as somnolent,57 this presentation is marked by psychomotor slowing and withdrawal, and may be misidentified as depression. The person may be lethargic (exhibiting little spontaneous activity) or drowsy, and may appear sedated.

Treloar and Macdonald suggest that the rate for the hypoactive or somnolent form may in fact be higher, but for a skewing arising from the DSM criteria for delirium.

A 78-year-old man with a mild dementia living in a low-care residential facility; after a brief period of hot water weather staff report that he appears to be experiencing episodes of ‘confusion’ which are largely episodes of disorientation to his environment. At these times he also tends to be unmotivated and withdrawn, needing almost complete direction with ADLs.

Hyperactive

Liptzin & Levkoff35 suggest that the hyperactive form – the presentation most commonly attributed to delirium – accounts for approximately 25% of cases, while Camus, Gonthier, Dubos et al. found rates of the hyperactive form to be approximately 46%.9 Also described as activated, it is marked by psychomotor agitation, rambling speech, delusions, hyperarousal and hyperalertness. It may be misidentified as anxiety, psychosis or mania because of the incidence of hallucinations, delusions and illusions and the increased likelihood of agitated behaviour.

Treloar and Macdonald contend that high rates may be an artefact of the DSM criteria that they argue favours ‘active’ phenomena like hallucinations and delusions.

An 84-year-old woman with a moderate dementia living in a high care residential facility has recently has been diagnosed with glaucoma for which she has been treated with timolol eye drops.

She now has episodes of uncharacteristic agitation and aggression and appears to be experiencing visual hallucinations (she has been seen picking at the air). At these times personal care is difficult and her level of function declines.

Mixed Hypoactive/Hyperactive

Mixed presentations are perhaps the most common form, accounting for up to 50% of cases. This presentation is marked by obvious fluctuations in activity level, cognitive disturbance, level of consciousness and organisation of thinking. People with the mixed form can often exhibit features of both active and somnolent forms so it is perhaps better viewed as alternating hypo- and hyperactive delirium.

Because visual hallucinations/illusions and delusions are sometimes described, a mixed delirium can be misidentified as a bipolar disorder.

A 72-year-old woman was admitted to a medical ward with pneumonia. The history suggests a decline in memory over the last 18–12 months but her daughter describes a significant decline over the last 3–4 days with symptoms worse at some times than others. In hospital, staff describe her as being mostly pleasantly confused (family adds that she seems to be a little more withdrawn than normal) but also speak of episodes of irritability and hyperactivity; at these times she is difficult to reason with and assertive yet 'confused'.

Subsyndromal Delirium

It is not uncommon for people to present with many – but not all – of the symptoms described in diagnostic classifications such as DSM-IV. Subsyndromal delirium is a term less commonly seen now, describing presentations where incomplete symptoms are exhibited.

Intervention in these cases is important, but recognising a partial syndrome may be difficult. There may be benefit in looking at delirium as a continuum, as, given the risks, it is probably in the interests of the patient to be over-inclusive.

The inclusion of possible false positives in management may simply be an appropriate response to the presence of one or two primary features, rather than the full syndrome. In all of these presentations it is important to be aware of the impact of symptoms (fluctuating sensorium, impaired attention) on the person’s day-to-day function and their capacity for any independent activity.

Sundowning

Confusion that arises in the late afternoon is often referred to as ‘sundowning’. Drake, Drake and Curwen describe sundowning as a ‘syndrome of recurring confusion and increasing levels of agitation, which coincide with the onset of late afternoon and early evening (p37).’

When these symptoms occur it is important to differentiate between: a) regularly occurring behaviour exhibited by a person with established dementia; and b) a similar set of features that have arisen over a short period of time.

An assumption that behaviour is sundowning may lead to the misidentification of a delirium. Until delirium has been excluded it is prudent to assume that all changed behaviour is delirium.

This section has explored the features and dynamics of delirium. The next section details practice strategies to assess and manage those suffering from delirium.Top of page

Managing Delirium

Introduction

This section explores assessment and management strategies for those caring for older people experiencing changes in thinking, function and behaviour.

Assessment is the first step in diagnosis of any disorder. It involves the systematic evaluation and measurement of psychological biological and social factors presenting in an individual. Careful assessment leads to the provision of safe and effective management, and the increased likelihood of an amelioration of symptoms.

Assessment

Identifying changes (in cognition, behaviour and function), and determining the history of these changes, is an important step in assessment: When did the change start? What sort of change is there? What might be causing it?

Initial assessments should include complete histories of recent changes, utilising information obtained from carers and/or care staff. The observations of family members and care workers are very important, and may be the first indication that something is happening. Phrases such as '...a bit off...', or '...off with the fairies...' or simply '...different...' are not uncommon - the coded speech Dr Henschke speaks of in the Preface. As delirium is a disorder of cognition it is important to determine how a person’s thinking and memory are affected.

Formal cognitive screens - using validated screening tools - may demonstrate cognitive impairment (or change) and can be compared to a baseline. Screening tools should be used as part of a complete assessment and with a clear purpose in mind. They do not identify the cause of impairment, but assist in alerting treatment teams to the presence of possible disorder or functional change. Whenever possible they should be administered by trained health professionals educated in their application, use and interpretation.

Routine screening of cognitive function (and the appropriate investigation of changes in cognition and function) helps identify those at risk of delirium and improve their management. It is important to assess the cognitive function of older (particularly frail) people, as the outcome of an assessment can affect diagnosis, choice of interventions and a person's ability to engage with treatment.

Just as a person’s blood pressure is taken at intervals to provide a baseline, cognitive screening is an integral part of the ongoing assessment of older people. Ongoing assessment and screening is necessary while an alteration in cognitive function persists.

Due to the fluctuating nature of delirium it is useful to assess people suspected of experiencing a delirium a number of times over the course of the day (perhaps morning and evening) and during the period of the admission to a health service, or while in a residential facility.

Cognitive Screening

Screening for cognitive impairment is useful as it provides: a) some objective measure of current cognitive function; and b) a baseline against which subsequent screening can be compared to demonstrate fluctuations, improvement or decline. However, screening tools are not diagnostic and should not be considered so.

There is benefit in completing a cognitive screening tool initially, and using information drawn from that process, as well as clinical interviews and subsequent history, however structured professional clinical judgement requires the use of a number of different sources of information to reach a comprehensive assessment.

The 'North of England Evidence Based Guideline Development Project' has developed an accessible examination of cognitive screening for the primary care context.

The Clock Drawing Test

The Clock Drawing Test (Screening Tools available via the PDF) is a useful brief screening tool that will indicate visuospatial ability, comprehension, attention, logic and evidence of perseveration. Its use as a screening tool is widely supported.

The results of such a screen for someone with a delirium might reveal disorganised thinking, poor planning and reasoning; poor visuospatial ability and distractibility (in that concentration will be diminished) – i.e. they will have difficulty focussing on the task. A particular advantage of The Clock Drawing Test is that it is easy to administer.

Royall DR, Cordes JA, & Polk M, 1998. CLOX: an executive clock drawing task. Journal of Neurology, Neurosurgery & Psychiatry (5):588–94.

Other Cognitive Screening Tools

Memory tests may not always actually test memory – due to a person’s impaired attention – but screening will help demonstrate an impairment. The Heidelberg Cognitive Screen (Screening Tools available via PDF) is presented here as it encourages clinicians to consider areas of strength and deficit, rather than focussing on a score. It does not require operators to be trained in its use.

Heidelberg Cognitive Screen Department of Neuropsychology, Austin & Repatriation Medical Centre. (Repatriation Campus) Banksia Street, Heidelberg Western Australia, 3081.

The Mini-mental State Examination is a commonly used screening tool in primary care, and although designed to screen for Alzheimer’s disease may contribute to the investigation of cognitive impairment. It requires that operators undertake some training in its use.

Folstein M, Folstein S, & McHugh P, 1975. The Mini-mental State: a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 12(3):189–98.

A Assessment of 'Confusion'

The Confusion Assessment Method (Screening Tools available via the PDF) is a tool increasingly mentioned in delirium literature, and is essentially an operationalisation of the DSM diagnostic criteria. It provides a structured format that allows the cardinal features of delirium (fluctuating symptoms, an acute onset and a change in cognition) to be identified from information derived from cognitive screening and the clinical interview, and used to complete the screen.

Inouye S, van Dyke C, Alessi C, Balkin S, Siegal A & Horowitz R, 1990. Clarifying confusion: the confusion assessment method. A new method for detecting delirium. Annals of Internal Medicine 113(12):941–8.

Other 'Confusion' Screening Tools

The Delirium Rating Scale and The NEECHAM Confusion Scale are screening tools for delirium,
see: Trzepacz P, Baker R, Greenhouse J, 1988. A symptom rating scale for delirium. Psychiatric Research 23(1):89–97. Neelon VJ, Champagne MT, Carlson JR & Funk SG, 1996. The NEECHAM Confusion Scale: construction, validation, and clinical testing. Nursing Research 45(6):324–30.

Risk factors include:

• existing cognitive impairment
• more than 3 drugs or recent changes to regimen
• use of urinary catheter and/or immobility
• iatrogenic events
• malnutrition
• visual and hearing impairment
• use of physical restraints
• ageing
• dehydration
• institutional care
• sleep deprivation Top of page

Differentiating Delirium, Depression and Dementia

	Early Dementia	Delirium	Depression
Onset	insidious (over months); symptoms often fluctuate	Relatively sudden – over hours to days; symptoms tend to fluctuate	over days to weeks
Prognosis	not reversible but manageable	recovery likely with treatment; high mortality if left untreated	risk of suicide; recovery likely with treatment
Behaviour	social skills may be preserved; withdrawal from social activities as memory deteriorates; may get lost in unfamiliar environments	disturbed sleep/wake cycle; hyperactive form may be restless; hypoactive form may present as somnolent, withdrawn	often slowed, occasionally agitated; changes to sleep, energy and appetite
Cognition
Memory	impaired, especially for recent events	impaired	may seem impaired; actually slowed
Attention	intact	poor; fluctuates	may appear impaired
Reasoning	declining	poor	often slowed
Language	may have naming; word-finding problems	variable	intact
Orientation	may have difficulties with time and place	disoriented	may appear disoriented
Consciousness	clear	clouded	clear
Affect	may be normal; may be flat or withdrawn; mildly perplexed	fluctuating: may be irritable; may be flat, withdrawn	sad or withdrawn or irritable, depressed, worried; helpless, guilty
Thought	shallow content; may appear to have paranoid ideas due to memory problems	may lack coherence; possible delusions	slowed or decreased; focus on past [guilt]; hypochondria; thoughts of death; possible mood-congruent delusions
Perceptions	often no change	simple misinterpretations; visual hallucinations	occasional auditory hallucinations
Speech Content	repetitive; patient unlikely to complain of cognitive deficits	Fluctuating; may be incoherent; non-fluent or fluent	coherent; often slowed; may complain of deficits
Judgement	declining	often impaired	may seem impaired
Insight	reduced awareness of difficulties	poor	variable

Begin with the rule of thumb that delirium develops over hours, depression over days or weeks, and dementia develops over months and years. Information derived from the history and screening is important for an accurate diagnosis and should be made available to others in care teams or provided in any referrals.

Ask yourself:

• is the cognitive impairment new?
• what was it like two months ago?
• is it part of an established dementia?
• has a cognitive screen been done?

In thinking about probable delirium acknowledge that:

• delirium is rarely caused by one thing – look for all likely causes and treat if known/found (e.g. drug-, infection-, metabolic disorder-, or dehydration-related)
• lack of obvious pathology does not mean it is not delirium
• with new-onset cognitive impairment or a recent acute change in mental function there is benefit in information obtained in an organic screen (usually CUE, FBE, ESR, B12 and folate, urinalysis and chest X-ray)
• to facilitate early identification of delirium in people receiving care it is useful to create an ongoing process of assessment and review of cognitive function:

1. conduct cognitive screen (e.g. Clock Drawing Test) on admission, or three-monthly in residential care, or when acute change occurs
2. complete further screening if acute impairment is present
3. conduct daily cognitive screens if delirium is thought to be present.

For people with significant impairment (acute or chronic) regular and clear documentation of behaviour is important.

Identify those at risk – hopefully before they develop a delirium.

Overview of Management

Management of delirium can only occur if it is recognised.

Delirium should be assumed with any change in thinking and behaviour that occurs over a couple of days.

The first thing to do is identify any causes and address them. If a cause is found, look to ensure that there are no others then look for the presence of risk factors and address those.

It is advisable to begin assessment at the point of first contact with a person as part of a health assessment – if nothing else it allows a baseline against which future assessment can be compared. This is relevant for any first contact or as soon as symptoms of impaired cognition become apparent.

There is evidence that people with disordered mental and cognitive function are likely to be seen as difficult and complex. They may therefore be less likely to receive adequate or appropriate nursing care. Cognitive impairment and agitated or aggressive behaviour makes this more likely. This fact should be borne in mind and actively guarded against.

Drug Treatment

The pathology of delirium appears to result, in part at least, from a disturbance of cholinergic function in the central nervous system, and the clinical evidence strongly supports this view. Delirium commonly occurs in drug toxicity arising from anticholinergics and particularly by centrally acting anticholinergic agents.

By inhibiting the enzyme responsible for the breakdown of acetylcholine it has been hypothesised that drugs (such as donepezil, rivastigmine, galantamine or tacrine hydrochloride) will augment cholinergic activity in the brain and facilitate the resolution of the delirium. Whether this is supported by controlled studies remains to be seen, and this may not be a useful treatment in delirium arising from other causes (i.e. metabolic).

Physical Care for Existing Delirium

Providing care for people with delirium differs little from care provided for any person with cognitive impairment and reduced capacity for self-care. The key to management is making days more predictable and minimising change – in the environment, in care practices, and staff – and avoiding the introduction of anything new or unfamiliar.

A rigid routine to deliver the care that a person is unable to provide or organise for themselves is beneficial: meals, hygiene, and rising in the morning / retiring at night at the same times each day is recommended, with assistance from the same people as much as possible, until the delirium resolves.

Symptomatic treatment is as important, as treatment of causes of delirium and care should seek to meet the needs of individuals.Top of page

Interpersonal Issues

It can be helpful to remember that confused older people are commonly distressed by events they do not understand. Rarely is ‘difficult’ behaviour intentional, personal or intended to cause injury; it is most likely defensive or an attempt to control their environment. It is also probably appropriate for their reality.

Speak in a clear voice with simple instructions and one-step directions to avoid overloading and further confusion. Remember that the fluctuating nature of delirium means patients may be lucid at some times and confused at others, or anywhere in between.

When lucid they may have good recall of events and conversations that have occurred whilst they were confused. Equally, they may have no memory at all. When providing care avoid hurrying or rushing and – particularly where cognitive disorder is present or suspected – avoid extremes of expressed emotion, as they may be misinterpreted.

A clear explanation of the disorder to the family is important. It can be comforting to know that delirium is largely reversible, but that it can include delusional and perceptual disorders (which may lead to unexpected verbal and physical behaviour).

The management of people with delirium is much the same as for anyone with cognitive impairment. What is important is not so much that cognitive impairment exists (although that does contribute to risk and is important in management) but that a person’s thinking and behaviour is changed, that the change occurred over a short time, and that their capacity will fluctuate.

Changes may affect their ability to care for themselves or receive care from others. This is as relevant for people who perform relatively well on screening tools as for people who do not.

Managing the Symptoms

The following information is drawn from Inouye, Bogardus, Charpentier et al.24 and Rapp. Both provide excellent guidelines for management.

Addressing cognitive impairment:

• use single issue questions
• use single issue directions
• repeat information
• minimise staff changes
• orientate to surroundings as appropriate (depending on tolerance)
• use large face clocks
• use large print calendars
• discuss/converse with patients; use games/activities as tolerated
• maximise lighting during daytime
• use low lighting at night
• encourage visits by significant others or volunteers
• relocate patients nearer nurses station if necessary (especially at night) to increase the sense of safety and contact (but staff need to be more mindful of noise and light).

Ensure Adequate Rest/Sleep:

• determine normal pattern
• establish regular waketime
• provide adequate pain relief
• establish regular bedtime
• ensure appropriate bowel management
• discourage excessive daytime napping
• encourage periods of activity (standing/walking)
• encourage periods of rest (need to programme activity throughout the day?)
• address lighting: more during day and subdued at night, as necessary
• reduce caffeine (including many carbonated drinks) intake after dinner.

Sleep is often problematic due to disturbances in the sleep wake cycle. Allow rests during the day and encourage maintenance of routine in the evening prior to settling. Unnecessary medication should be avoided but where appropriate short-term use of medium acting benzodiazepines (e.g. oxazepam) is preferred.

Oversedation is a safety risk, resulting in a greater likelihood of falls and increased confusion. Sleeping with a nightlight on can be beneficial, as it reduces the likelihood of misinterpretation of the environment should waking occur.

Ensure Adequate Hydration and Nutrition (Provide prompts if appropriate)

Hydration

• fluid intake adequate?
• check oral mucosa for dehydration
• determine favoured fluids
• encourage regular fluids
• fluids available and within reach
• daily/weekly weigh as necessary
• refer to dietician as necessary

Nutrition

• is diet appropriate?
• record and evaluate intake/output
• determine favoured foods; encourage family to bring in favourite foods/fluids
• small frequent meals and/or fingerfoods and/or supplements if necessary
• encourage sitting up for meals
• facilitate socialisation during meals
• refer to dietician as necessary

Prior to Offering Hypnotics:

• offer relaxation or tape music (their choice)
• encourage warm milk or herb tea at supper
• provide slow backrub (5min)
• Provide/enforce sleep-protect time (about 2300–0600)
• if person awake after 1/24 (or declines alternatives) offer usual care (e.g. sedatives)

Ensure Adequate Exercise - Facilitate Mobility:

• determine if immobility exists
• determine if immobility is imposed
• evaluate need for immobility
• evaluate cause of immobility
• arrange physiotherapy and consult if necessary
• address need/cause (e.g. use of urinary leg bag instead of overnight bag)
• facilitate mobility (e.g. walk to toilet)
• determine need for aid
• encourage periods of activity (standing or walking) interspersed by periods of rest
• encourage out-of-bed sitting if person seeks bed (see ‘sleep’ and ‘nutrition’ sections).

For hypoactive people, exercise is important: simply standing against a table a few times a day can be enough to maintain tone. For hyperactive people, rest is important: decrease stimulation by moving to low stimulus areas (away from noise, traffic etc).

For patients who are active, a low stimulus environment is less likely to lead to agitation; television should be avoided as it is distracting and produces agitation, increasing hallucinations, delusions and disorientation. Soft music is comforting and relaxing for most people, as is use of mild aromatherapy.

Address Visual and Auditory Impairment

Vision

• Do they wear glasses?
• Do they need glasses?
• Test vision
• Are their glasses clean and within reach?
• Is lighting adequate for purpose?
• If available, is a call bell within reach? – can they find it easily?
• Would a portable whiteboard help?

Hearing

• Do they wear an aid?
• Test hearing
• Are their aid(s) functioning and within reach? – check the battery
• Assess the need for a portable amplifying device
• Is background noise excessive?
• Reduce ambient noise to minimise stimulation
• Speak in a clear and unhurried mannerTop of page

Aggressive Behaviour

If the person is aggressive (often in the form of agitation or resistiveness):

• address their safety
• address the safety of carers and staff
• if the situation is not safe, withdraw
• provide simple, clear directions
• use calm, unemotional speech
• display low expressed emotion; adopt a ‘professional and polite’ manner
• listen and discover what the issue is
• reinforce desired behaviour
• use restraints (chemical and/or physical) as a last resort.

Aggression is one of the few issues that may respond to pharmacological management BUT: start low and go slow with the increases (and only if you are sure that a drug works).

Listen to the person, ask what is wrong, look for reasons, and try to address their issues before using restraints:
minimise use of drugs that have a high likelihood of causing or increasing delirium (particularly opioids, anticholinergics).

This knowledge does not stop difficult behaviour, but may help health professionals consider the costs of pharmacotherapy, as well as help them understand there may be greater benefit in accepting that a person may be distressed. It suggests there is more to be gained from spending more time with an agitated or aggressive person, to address underlying issues that may be contributing to the person’s distress.

Working with Families or Significat Others

Family members need to know that delirium is largely reversible, although it can take time to resolve completely. Supporting family members and helping them to understand and deal with symptoms is a component of comprehensive care. An awareness that a patient’s misidentification of family members is due to their mental state can reduce family disharmony.

Can we involve them in care? They may be happy to become part of the management team, visiting to provide social interaction or just read the newspaper, for example. They may make adjustments to the times they visit, or arrange with other family members and friends to visit frequently in small groups, to avoid overstimulation but provide social contact over a longer period. The role of family in management needs to be negotiated with them, so as not to add to their burden.

End of Life Issues

Delirium occurs in up to 85% of people near the end of life. Risk factors are essentially the same as for other people, but there can be an increased risk due to the use of opioids and psychotropics.

For any cognitive impairment – and for delirium in particular – identification is vital. However, delirium management at the end of life should be balanced with a patient’s comfort. Some features may be better left unaddressed if they do not lead to patient distress, or would lead to deterioration in quality of life or symptoms if addressed.

For example, hallucinations may include long-lost friends or family, and may provide comfort and support, rather than distress. Equally, reducing opioids to provide better management of the symptoms of delirium must be balanced by comfort needs.

Conclusion

Delirium, rather than being a disorder, is a clinical syndrome. It is a relatively common health problem in old age, with those in hospitals or residential care at particular risk.

It is marked by an acute disturbance of attention and cognition, and often forecasts physical, functional and cognitive decline – and a need for a higher level of care if untreated.

It is important to identify people with acute cognitive impairment as this reversible syndrome may be the only indicator of the presence of physical disorder. Although it is seen as having a short duration, to describe delirium as transient is to ignore the evidence.

Cognitive decline must be recognised as an abnormal event in older people, rather than as a normal part of ageing. Comprehensive assessment and management of alterations in cognitive function can prevent and arrest the incidence of delirium. Top of page

Glossary

anticholinergic opposing or blocking the action of acetylcholine (a chemical in the brain involved with communication between brain cells).
cholinergic involving or resembling the neurotransmitter acetylcholine, especially in physiologic action.
iatrogenic induced inadvertently by a medical practitioner, medical treatment or diagnostic procedures.
labile changeable, unstable; fluctuating mood.
lucid intelligible; being sound mentally, or rational.
metabolic relating to, or resulting from metabolism.
mnemonic having to do with improving memory.
narcotic any derivative, natural or synthetic, of opium or morphine or any substance that has their effects; potent painkillers that can cause sedation or sleep.
neuroleptic a drug from the antipsychotic or major tranquilliser group.
opioid derived from opium or a synthetic narcotic resembling opium (e.g. morphine).
organic pathology disease of the body, an organ or organ system; physical illness.
paradoxical not the normal or expected thing.
perseveration the repetition of a word, phrase or idea, or action.
psychomotor of, or relating to, motor activity that arises directly from mental activity.
psychomotor agitation an abnormal restlessness of thought and action; usually irresistible.
psychomotor retardation an abnormal slowness of thought and action; usually irresistible.
psychotropic drugs that act on the brain (e.g. sedatives, minor and major tranquilisers, mood-stabilisers/anti-epileptics).
regimen treatment guide or plan often associated with medications.
sensorium to do with the senses.
somnolence sleepiness, drowsiness; overwhelming fatigue.
systemic relating to the system (body).
visuospatial referring or relating to the visual perception of spatial relationships among and between objects.Top of page

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