Get Clear on Delirium
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 Some people may become withdrawn and lethargic, while others become agitated or hyperactive.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
