Delirium in Older Adults: Types, Causes, and Symptoms

 
Delirium in older adults
 
Tier 3
 
Delirium
 
Delirium is an aetiologically nonspecific syndrome
 
 It can include disturbances of
Consciousness and attention
Perception
Thinking
Memory
Psychomotor behavior
Emotion
Sleep-wake cycle
 
Course of delirium
 
 
Usually transient and of fluctuating intensity
 
Most cases recover within 4 weeks or less
However, some may take up to 6 months
 
The delirious state may be superimposed on, or progress into,
dementia.  (ICD-10, 1992.)
 
Delirium is associated with increased length of hospital stay,
functional decline, increased morbidity and mortality and
increased rates of institutionalization
 
Types
 
 
Hyperactive 
- most easily recognized type, this may include
restlessness (for example, pacing), agitation, rapid mood changes
or hallucinations, and refusal to cooperate with care.
 
Hypoactive
 - may include inactivity or reduced motor activity,
sluggishness, abnormal drowsiness, or seeming to be in a daze. This
is often missed
 
Mixed 
- both hyperactive and hypoactive signs and symptoms. The
person may quickly switch back and forth from hyperactive to
hypoactive states.
 
 
Causes
 
Causes are often complex and multifactorial
D
 
Drugs  including: opioids, anticholinergics, steroids, benzodiazepines,
antidepressants, sedatives, dehydration, detox, deficiencies, discomfort
(pain) -dementia
E 
 
Electrolytes (sodium, glucose, calcium ), elimination abnormalities,
environment
L
 
Lungs (hypoxia), liver, lack of sleep
I
 
Infection, iatrogenic events, infarction (cardiac, cerebral)
R
 
Restricted movement/mobility, renal failure/removal of alcohol
I
 
Injury, impaired sensory input, intoxication
U
 
UTI, unfamiliar environment
M
 
Metabolic abnormalities (glucose, thyroid), metastasis (brain)
COVID causes delirium
 
Symptoms
 
Acute onset
Fluctuating course
Inattention
Disrupted sleep pattern
Reduced awareness
Reduced alertness
Altered consciousness & a change in cognition
Hallucinations – usually visual
Fleeting delusions
Labile affect
Orientation – variably impaired
Memory – immediate & recent impairment
 
P
r
e
d
i
s
p
o
s
i
n
g
 
F
a
c
t
o
r
s
 
Factors that have been identified as predisposing a patient to develop a
delirium include:
Advanced age
Cognitive impairment
Severity of underlying illness
Depression
Dehydration
Sensory impairment
Functional impairment
Physical health conditions – stroke, neurological diseases, chronic
renal or hepatic diseases
 
Precipitating Factors
 
Events related to either hospitalisation or associated treatments can
precipitate the development of delirium:
Surgical procedures – high incidence due to multiple insults to the body
Infection
Electrolyte imbalance
Disruption to sleep cycle
Change in medication regimes / multiple medications /  medication
errors
Pain
Unfamiliar environment
Poor nutrition / hydration
Constipation
Drug / alcohol withdrawal
 
Pathophysiology
 
Delirium = acute medical condition.
 
Pathophysiology is poorly understood.
 
Likely related to multiple physiological mechanisms that affect
neurotransmission, inflammation and stress responses.
 
Disease and / or trauma leads to a physical stress response.
 
Stress response overwhelms the individual due to deranged
neurotransmitter release and uptake.
 
Diagnosis
 
Clinical assessment is key
 
Consider using Confusion Assessment Method (CAM) as a
screening tool or 4AT
 
Get an accurate history from someone who knows the
patient
 
10
 
3+  – possible delirium 
+
 cog impairment
1-3 – possible cognitive impairment
0    – delirium unlikely
 
M
a
n
a
g
e
m
e
n
t
 
Address any infection and pain
Ensure adequate hydration and nutrition
Ensure glasses, hearing aids etc. are accessible
Attention to the environment is essential.
Quiet area or side room; limit staff changes
Adequate lighting, minimise noise, provide a clock the patient can see
Gentle repeated reorientation and to avoid confrontation
Try to maintain normal sleep-wake cycle
 
EXPLANATION is KEY
Explain cause and likely course to patient, relatives and carers
Address anxiety; patients with delirium are often frightened
Explain the organic cause of behaviour and symptoms
 
13
 
M
a
n
a
g
e
m
e
n
t
 
Identify the underlying cause and treat appropriately
 
Manage the symptoms of delirium whilst the cause is
found
 
Prevent injury and delirium complications—falls,
wandering, harming self or others, skin breakdown,
aspiration
 
Address predisposing & precipitating factors as
appropriate
 
 
M
a
n
a
g
e
m
e
n
t
 
Non-pharmacological measures to manage symptoms should be
tried first  which can include nursing in a single room, reorientation, using
of appropriate lighting, offering reassurance
 
Assess for short term use of low dose antipsychotic medication if
patient is disturbed by hallucinations or severe agitation and aggression.
Sedatives and hypnotics can prolong delirium therefore they should
be used judiciously and in minimal doses
Combative and physically dangerous patients may require urgent
reassessment
 
 
Delirium resources
 
HEE NE > PG Dean > Faculty of Patient Safety > Delirium Project
This link has link to animated videos on delirium awareness and
on being delirium ready.
 
Patient video (europeandeliriumassociation.org)
 This is the link
to powerful video of what it is like to experience delirium.
 
Leaflets for patients and relatives: https://www.rcpsych.ac.uk/mental-
health/problems-disorders/delirium
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Delirium in older adults is a complex syndrome characterized by disturbances in consciousness, attention, perception, thinking, memory, and behavior. It commonly presents as hyperactive, hypoactive, or mixed types and can be caused by various factors such as medication, infections, metabolic imbalances, and environmental issues. Recognizing the symptoms, including acute onset, fluctuating course, inattention, disrupted sleep pattern, and altered cognition, is crucial for timely intervention. Predisposing factors like advanced age, cognitive impairment, and underlying illnesses increase the risk of developing delirium. Early identification and management are essential to prevent complications and promote recovery in older adults.

  • Delirium
  • Older Adults
  • Causes
  • Symptoms
  • Cognitive

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  1. Delirium in older adults Tier 3

  2. Delirium Delirium is an aetiologically nonspecific syndrome It can include disturbances of Consciousness and attention Perception Thinking Memory Psychomotor behavior Emotion Sleep-wake cycle

  3. Course of delirium Usually transient and of fluctuating intensity Most cases recover within 4 weeks or less However, some may take up to 6 months The delirious state may be superimposed on, or progress into, dementia. (ICD-10, 1992.) Delirium is associated with increased length of hospital stay, functional decline, increased morbidity and mortality and increased rates of institutionalization

  4. Types Hyperactive - most easily recognized type, this may include restlessness (for example, pacing), agitation, rapid mood changes or hallucinations, and refusal to cooperate with care. Hypoactive - may include inactivity or reduced motor activity, sluggishness, abnormal drowsiness, or seeming to be in a daze. This is often missed Mixed - both hyperactive and hypoactive signs and symptoms. The person may quickly switch back and forth from hyperactive to hypoactive states.

  5. Causes Causes are often complex and multifactorial D Drugs including: opioids, anticholinergics, steroids, benzodiazepines, antidepressants, sedatives, dehydration, detox, deficiencies, discomfort (pain) -dementia E Electrolytes (sodium, glucose, calcium ), elimination abnormalities, environment L Lungs (hypoxia), liver, lack of sleep I Infection, iatrogenic events, infarction (cardiac, cerebral) R Restricted movement/mobility, renal failure/removal of alcohol I Injury, impaired sensory input, intoxication U UTI, unfamiliar environment M Metabolic abnormalities (glucose, thyroid), metastasis (brain) COVID causes delirium

  6. Symptoms Acute onset Fluctuating course Inattention Disrupted sleep pattern Reduced awareness Reduced alertness Altered consciousness & a change in cognition Hallucinations usually visual Fleeting delusions Labile affect Orientation variably impaired Memory immediate & recent impairment

  7. Predisposing Factors rs Factors that have been identified as predisposing a patient to develop a delirium include: Advanced age Cognitive impairment Severity of underlying illness Depression Dehydration Sensory impairment Functional impairment Physical health conditions stroke, neurological diseases, chronic renal or hepatic diseases

  8. Precipitating Factors Events related to either hospitalisation or associated treatments can precipitate the development of delirium: Surgical procedures high incidence due to multiple insults to the body Infection Electrolyte imbalance Disruption to sleep cycle Change in medication regimes / multiple medications / medication errors Pain Unfamiliar environment Poor nutrition / hydration Constipation Drug / alcohol withdrawal

  9. Pathophysiology Delirium = acute medical condition. Pathophysiology is poorly understood. Likely related to multiple physiological mechanisms that affect neurotransmission, inflammation and stress responses. Disease and / or trauma leads to a physical stress response. Stress response overwhelms the individual due to deranged neurotransmitter release and uptake.

  10. Diagnosis Clinical assessment is key Consider using Confusion Assessment Method (CAM) as a screening tool or 4AT Get an accurate history from someone who knows the patient 10

  11. 4AT Tool (circle score in each section on right and total score) Alertness: This incudes patients who are markedly drowsy (e.g. difficult to rouse and/or obviously sleepy during assessment) or agitated /hyperactive. Observe the patient if asleep, attempt to wake. Ask patient to state name and address to assist rating. AMT4 (Age, D.O.B, place(hospital), current year) Circle Normal (fully alert, but not agitated, throughout assessment) 0 Mild sleepiness for <10 secs after waking then normal 0 Clearly abnormal 4 No mistakes 1 mistake 0 1 2 0 1 >2 mistakes/untestable Attention: Ask the patient : "please tell me the months of the year in backwards order, starting at December." Achieves 7 months or more correctly Starts but scores <7 months/refuses to start Untestable (cannot start because unwell, drowsy, inattentive) 2 Acute change or fluctuating course: Evidence of significant change or fluctuation in alertness, cognition, other mental function (e.g. paranoia, hallucinations) arising over the last 2 weeks and is still evident in last 24 hours. No 0 Yes 4 Total 3+ possible delirium + cog impairment 1-3 possible cognitive impairment 0 delirium unlikely

  12. Management Address any infection and pain Ensure adequate hydration and nutrition Ensure glasses, hearing aids etc. are accessible Attention to the environment is essential. Quiet area or side room; limit staff changes Adequate lighting, minimise noise, provide a clock the patient can see Gentle repeated reorientation and to avoid confrontation Try to maintain normal sleep-wake cycle EXPLANATION is KEY Explain cause and likely course to patient, relatives and carers Address anxiety; patients with delirium are often frightened Explain the organic cause of behaviour and symptoms 13

  13. Management Management Identify the underlying cause and treat appropriately Manage the symptoms of delirium whilst the cause is found Prevent injury and delirium complications falls, wandering, harming self or others, skin breakdown, aspiration Address predisposing & precipitating factors as appropriate

  14. Management tried first which can include nursing in a single room, reorientation, using of appropriate lighting, offering reassurance Non-pharmacological measures to manage symptoms should be patient is disturbed by hallucinations or severe agitation and aggression. Sedatives and hypnotics can prolong delirium therefore they should be used judiciously and in minimal doses Combative and physically dangerous patients may require urgent reassessment Assess for short term use of low dose antipsychotic medication if

  15. Delirium resources HEE NE > PG Dean > Faculty of Patient Safety > Delirium Project This link has link to animated videos on delirium awareness and on being delirium ready. Patient video (europeandeliriumassociation.org) This is the link to powerful video of what it is like to experience delirium. Leaflets for patients and relatives: https://www.rcpsych.ac.uk/mental- health/problems-disorders/delirium

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