Geriatric Quick Consult
Delirium DOs and DON'Ts
Delirium: acute confusion, sundowning, AMS, agitationThis acute disorder of brain function is common in the elderly, particularly when ill or hospitalized. Often, delirium is what brings the patient to the hospital. Research has revealed much about evaluation and management of delirium, though we still do not fully understand the physiology at a cellular or molecular level. For example, a patient with dementia may become delirious with a urinary infection even though the CBC, vital signs, oxygenation, and basic blood chemistry are normal. Delirium usually occurs in people with underlying brain disorders like Alzheimer's disease or stroke. The underlying brain disorder may be mild and sometimes is not yet even recognized. Minor physiologic stress can tip the scales for these patients. Perfectly healthy elders also get delirium, but the stressor required is greater.Unlike dementia, delirium is an acute or subacute condition with a reversible cause (MORE DETAIL, REFS). Altered level of arousal (either over-active or under-active) and fluctuation in cognition and behavioral problems throughout the day and night is common. Knowing the patient's baseline mental and functional status is essential. Often a close family member or continuing care physician can judge this better than providers new to the case. Subtle changes make a big difference. Problems like failure to eat, calling out, wandering, or sleeping more than normal may be the key manifestations. Medications, including anesthesia, infections, and physical discomfort may be the cause. So can sensory deprivation (hearing, sight), loss of familiar surroundings (sundowning), or departure from normal day-night cycles and sleep patterns. Some medications are particularly notorious causes, including CNS-active agents with long half-lives, and anti-cholinergic drugs. Delirium may be the presenting symptom of conditions that seem completely unrelated to the brain, such as myocardial infarction. Severe electrolyte or metabolic changes are not required. Older patients commonly have a delirium for a few days after surgery. Delirious older patients are at high risk of poor outcomes (MORE DETAIL, REFS). They stay in the hospital longer, get placed in nursing homes more often , and may die. Too often, a cascading series of events produces the bad outcome. The confused patient pulls at his IV, so he is restrained. Then a Foley is placed because of incontinence, leading to a UTI and the patient pulls the catheter out causing urinary obstruction and bleeding. Medications given to sedate the patient aggravate the problem and nutrition declines. Pressure ulcers develop. Sometimes delirium is preventable. In other cases it can be ameliorated (REF). The following chart has basic first steps, "DOs" and "DON'Ts." Click on them for more details. Specific treatment suggestions |
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