Delirium—also known as acute confusional state—is a common and potentially serious condition for hospitalized geriatric patients. It is believed to complicate hospital stays for more than 2.3 million older people, account for more than 17.5 million in patient days, and cost more than $4 billion in Medicare expenditures.1
Many experts believe the numbers may be higher because clinical staff too often automatically attribute patients’ symptoms to age-related dementia.
Delirium is many times more likely to occur in older people.2 Because patients older than 65 account for nearly half of all inpatient days, hospitalists must be readily able to identify the signs and symptoms of delirium—as well as what factors put certain patients at an increased risk for developing delirium. Hospitalists with this knowledge and ability will be better equipped to reduce the risk for delirium in their patients and more effectively treat delirium when it occurs.
“Assuming that the patient’s confusion is a normal state for him or her, without speaking to the patient’s family or caregivers to establish the baseline mental status for the patient, is probably the biggest reason delirium is so often misdiagnosed and, consequently, left untreated,” says Sharon Inouye, MD, of the Institute for Aging Research, Hebrew SeniorLife and Harvard Medical School.
Define and Diagnose Delirium
Delirium is a temporary state of mental confusion and fluctuating consciousness. Patients are unable to focus their thoughts or pay attention, are confused about their environment and individuals, and unsure about their daily routines. They may exhibit subtle or startling personality changes. Some people may become withdrawn and lethargic, while others become agitated or hyperactive. Some patients experience visual and/or auditory hallucinations and become paranoid.
Changes in sleep patterns are a typical manifestation of delirium. The patient may experience anything from mild insomnia to complete reversal of the sleep-wake cycle. All symptoms may fluctuate in severity as the day progresses, and it is common for delirious patients to become more agitated and confused at night.
Dementia is a chronic problem that develops over time. Delirium is acute—usually developing over hours or days. While patients with pre-existing dementia, brain trauma, cerebrovascular accident, or brain tumor are at higher risk for developing delirium, don’t automatically attribute unusual behavior in a geriatric patient to one of these diagnoses—especially if the behavioral change is sudden.
It is vital to obtain a solid history to determine the patient’s baseline mental status. The patient may not be the most reliable source of information regarding his or her normal level of cognition—particularly if he or she is beginning to show signs that may indicate delirium. Make every effort to question the patient’s family members and caregivers thoroughly to determine the patient’s normal level of functioning.
“The trick is that you have to have a nursing staff you can trust and who is attentive enough to changes in behavior—keeping in mind that they’ve only known the patient for a short time,” says Jonathan Flacker, MD, assistant professor of medicine at Emory University in Atlanta. “You have to rely a lot on the families and caregivers. You have to know whether the patient’s behavior is new or not, and sometimes that’s hard to establish.”
A simple tool nursing staff can use to monitor the patient’s mental status is the Confusion Assessment Method (CAM). The CAM is easy to use and interpret and only takes moments to complete. When staff on each shift use this tool and accurately document the results, it can help identify early changes that may indicate the onset of delirium.3
In addition to the CAM, other tools that can assist in cognitive assessment of the patient can include The Mini-Cog Assessment Instrument for Dementia, The Clock Draw Test, The Short Portable Mental Status Questionnaire (SPMSQ), The Geriatric Depression Scale, The Folstein Mini-Mental Status Exam, and The Digit Span Test.
Once the physician has determined that a patient is suffering from delirium, the challenge is to identify and treat the cause.
“It is important to remember that older folks often have atypical presentation of symptoms for medical problems,” says Dr. Inouye. “Physicians and clinical staff need to carefully consider all of the patient’s signs and symptoms, regardless of how insignificant they may seem.”
The physician can then order additional diagnostic tests based on the findings of the physical examination, which may include CBC, serum chemistry group, urinalysis, serum and urine drug screens, and possibly diagnostic radiographic studies as indicated.
Assessment must also include a careful review of the patient’s medications—possibly with input from a pharmacist. To do this, obtain a complete list of medications the patient was taking prior to admission to compare with the medications the patient is taking currently. Consider the possible effects of:
- Medications that have been discontinued;
- New medications;
- Changes in dosage;
- Possible drug interactions; and
- Possible drug toxicities that may require additional lab testing.
Pay attention to psychoactive medications the patient is taking, such as sedative-hypnotic agents, narcotics, and antidepressants. It is important to note whether the patient has recently received anesthesia or pain medications.4 It is also important to determine whether the patient has a history of alcohol or drug dependency.
“The first thing I would think if a patient is not acting right is drugs—some new drug that we’re administering or some drug that he or she is withdrawing from,” says O’Neil Pyke, MD, medical director of the Hamot Hospitalist Group in Erie, Pa. “You have to consider the possibility of side effects, drug interactions, and withdrawals. You also have to recognize polypharmacology as a major risk factor and try to curtail unnecessary medications.”
Dr. Flacker cautions that even once a problem has been identified, the physician must follow through on the complete examination and evaluation of the patient, keeping in mind that the cause for delirium may be multifactorial. “The problem is that like a lot of things in older folks, if you look for ‘the’ cause, you’re likely to be frustrated,” he says. “It’s often a combination of stressors causing the patient’s delirium.”
Once the underlying problem or problems have been identified, treat those medical conditions accordingly—by administering antibiotics, fluids, and electrolytes as needed and adjusting or discontinuing medications.
However, resolution of the etiologic cause does not necessarily mean the symptoms of delirium will spontaneously resolve. These symptoms likely will require specific interventions to reorient the patient.
Encourage family members to participate in these efforts and spend as much time as possible with the patient. It may also be helpful to have family members bring in a few familiar items from the patient’s home—such as family photographs—to help calm and reassure the patient.
David Meyers, MD, hospitalist and chief of inpatient medicine at the Veterans Administration Medical Center in Madison, Wis., says: “You can use very simple modifications that really don’t take much time or effort. It’s really trying to recreate the patient’s environment and getting him or her to identify with certain things.”
To help the patient remain oriented to time and assist with disturbances in sleep patterns, staff should turn lights on and off and open and close curtains and blinds at the appropriate times. Make wall calendars and clocks visible to the patient. Try to keep the patient as active as possible during the day and minimize sleep interruptions.
Maintain as calm an environment for the patient as possible, minimizing ambient noise and activity. Place the patient in a room without a roommate if possible, close enough to the nurses’ station to facilitate close observation—but not so close that they’re disturbed by beepers, telephones, monitors, and other noises. Keep televisions at a reasonable volume and turned off when no one is watching. However, don’t isolate or abandon the patient, or let him/her spend too much time in bed. Assist the patient with mobilization several times daily.
If the patient has a vision or hearing impairment, staff and family should make every effort to ensure that the patient has access to and uses the appropriate corrective devices.4 Staff will also need to pay special attention to ensure that the patient eats appropriately, maintains an adequate fluid intake, and is assisted to the restroom regularly.
If safety concerns make it absolutely necessary to use physical restraints on a delirious patient, remember to explain all actions and instructions in clear, simple terms, using a low, calm tone of voice. Apply restraints carefully, release at frequent intervals, and discontinue as soon as possible. The patient likely will not understand why he or she is being restrained—and this lack of comprehension can worsen the patient’s fear and agitation.4,5
If nonpharmacologic interventions are not effective in controlling the patient’s agitation, physicians may prescribe antipsychotic agents and intermediate-acting benzodiazepines to immediately control an extremely agitated patient. However, some antipsychotic drugs can have anticholinergic side effects, which may aggravate delirium. Benzodiazepines can also exacerbate the patient’s delirious symptoms in the long term. Use these medications only for initial control of the patient’s behavior, and reduce and discontinue as soon as possible.
Dr. Meyers encourages consultation by a geriatrician. “The biggest consult service I utilize for suggestion of treatment options is geriatrics,” he says. “They’re very good at working with the patient and family and thinking of other behavioral and medical modifications.
“We can’t give a pill to reverse delirium. This is a shift in paradigm from what physicians are taught. In this setting, you actually want to get rid of medications and limit interventions.”
Remember to reassure patients and their families that most people recover fully if delirium is rapidly identified and treated. However, also caution them that some of the patient’s symptoms may persist for weeks or months, and improvement may occur slowly. Discharge from the hospital may be in the patient’s best interest—but the persistence of symptoms may necessitate home healthcare or temporary nursing home placement.
“In the absence of an acute medical problem, it may be preferable to get the patient to a less acute setting that can be more orienting and more therapeutic,” says Dr. Flacker.
While experts agree that it is not possible to prevent every case of delirium, knowing what puts patients at higher risk gives us the ability to reduce that risk for many patients.
In 1999, Dr. Inouye and her colleagues at the Yale University School of Medicine developed The Hospital Elder Life Program (HELP). The HELP program utilizes a trained interdisciplinary team consisting of a geriatric nurse-specialist, specially trained Elder Life specialists, trained volunteers, geriatrician, and other consultants (such as a certified therapeutic recreation specialist, a physical therapist, a pharmacist, and a nutritionist) to address six facets of delirium risk:
- Orientation. Provide daily communication and a daily schedule on a dry-erase board or chalkboard;
- Therapeutic activities. A variety of cognitively stimulating, fun activities like word games, reminiscence, trivia, or current events;
- Early mobilization. Get all patients up and walking three times a day;
- Vision and hearing adaptations;
- Feeding assistance and hydration assistance with encouragement/companionship during meals; and
- Sleep enhancement. Provide a nonpharmacologic sleep protocol, such as warm milk or herbal tea, backrub, and relaxation music.
A study of the HELP program published in The New England Journal of Medicine showed a 40% reduction in risk for delirium when these measures were applied to at-risk patients included in the study. Implementing the program cost $6,341 per case of delirium prevented. That is significantly less than the estimated cost associated with preventing other hospital complications, such as falls and myocardial infarction.
Prevention is preferable to treatment. But when delirium cannot be prevented, Dr. Inouye concludes with this advice for hospitalists: “Recognition is huge. The single most important thing that hospitalists can do for patients suffering from delirium is to know the signs and symptoms and recognize them when they occur. Earlier recognition means earlier intervention—and that is what’s in the best interest of the patient.” TH
Sheri Polley is a frequent contributor to The Hospitalist.
- Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med.1999 Mar 4;340:669-676.
- Rummans TA, Evans JM, Krahn LE, Fleming KC. Delirium in elderly patients: Evaluation and management. Mayo Clinic Web site. Available at www.mayoclinicproceedings.com/inside.asp?AID=4031&UID. Last accessed May 14, 2007.
- Clinical Toolbox for Geriatric Care. Society of Hospital Medicine Web site. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.
- McGowan NC, Locala JA. Delirium. The Cleveland Clinic Web site. Available at www.clevelandclinicmeded.com/diseasemanagement/psychiatry/delirium/delirum1.htm. Last accessed May 15, 2007.
- Restraint Alternative Menu. Clinical Toolbox for Geriatric Care 2004 Society of Hospital Medicine. Available at www.hospitalmedicine.org/geriresource/toolbox/howto.htm. Last accessed May 2, 2007.