An 83-year-old woman presented with fever, shortness of breath, and poor oral intake. She has a history of multiple medical conditions and is on several medications. On examination, she has a fever and signs of respiratory distress. The physician is concerned about pneumonia and increased depression, but her cognitive status was not assessed. Delirium is an acute fluctuating syndrome of altered attention, awareness and cognition, especially common in elderly hospitalized patients. It is often misdiagnosed as depression or dementia. Non-pharmacological prevention and treatment of underlying causes are most important, while antipsychotics may be used short-term for severe symptoms if needed.

1. DELIRIUM IN
ELDERLY
Marwa Mahmoud Khalifa

2. Case
An 83 year old recently widowed woman who lives alone
is brought to her physician by her daughter for evaluation
of falling, fever, shortness of breath, and poor oral intake.
She has a history of diabetes, hypertension, congestive
heart failure, reflux esophagitis, and depression.
She is taking metformin, enalapril, digoxin, atenolol,
ranitidine, paroxetine, and lorazepam.
On examination, she has a low-grade fever, poor skin
turgor, dry mucous membranes, and audible wheezing
and rhonchi at both lung bases. She is sleepy,
withdrawn, and not cooperative with the examination.
Her physician is concerned about pneumonia and
increased depression. Her cognitive status is not
assessed.

3. What’s delirium??
Acute,
fluctuating
syndrome of
altered attention,
awareness, and
cognition.

4. Epidemiology
The overall prevalence of delirium in the
community is just 1–2%, but in the setting of
general hospital admission this increases to
14–24%.

6. Risk factors
Nonmodifiable risk factors
• Dementia or cognitive impairment
• Advancing age (>65 years)
• History of delirium, stroke, neurological disease,
falls or gait disorder
• Multiple comorbidities
• Male sex
• Chronic renal or hepatic disease

7. Risk factors
Potentially modifiable risk factors
• Sensory impairment (hearing or vision)
• Immobilization (catheters or restraints)
• Acute neurological diseases (stroke, intracranial
hemorrhage, meningitis, encephalitis)
• Sustained sleep deprivation

9. • Intercurrent illness (infections, iatrogenic
complications, severe acute illness, anemia,
dehydration, poor nutritional status, fracture or
trauma, HIV infection)
• Metabolic derangement
• Surgery /admission to an intensive care unit)
• Pain
• Emotional distress

10. Pathophysiology

12. Presentation
• unawareness, decreased alertness, sparse or slow
speech, lethargy, slowed movements, staring, or
apathy.
• most frequently in elderly
• misdiagnosed as having depression or dementia.
Hypoactive
• hyper vigilance, restlessness, fast or loud speech,
irritability, impatience, uncooperativeness, euphoria,
anger, wandering, easy startling, fast motor
responses, distractibility, nightmares, or persistent
thoughts
Hyperactiv
e
• both hyperactive and hypoactive features.Mixed

13. Tools for evaluation
 Confusion Assessment method (CAM)
 a standardized, brief, validated diagnostic
algorithm for the identification of delirium.
 The algorithm has a sensitivity of 94–100%, a
specificity of 90–95%,

15. Diagnosis
 The following criteria are derived from the
Diagnostic and Statistical Manual of Mental
Disorders.

17. Work up
1. Detailed assessment to search for the
precipitant
acute medical illness, a change in therapy, or the
destabilization of a chronic condition,
constipation and urinary retention
2. Physical examination
infection, volume depletion, abdominal
pathology,
deep vein thrombosis, and a neurological cause

18. Investigations
 ECG , troponin
 CBC with differential
 Electrolytes
 Liver enzymes, renal functions
 Thyroid function
 Chest x-ray
 Urinalysis and culture

19. Neuro imaging !!!
Is it mandatory ??
 Focal neurological deficits
 Suspected head trauma.
 Worsening severity or prolonged course

21. Non pharmacological strategies
for prevention

26. Involving the patient’s family, primary bedside
nurse, and clinical nurse leader in the creation of
a nursing care plan can also be instrumental in
the success of these non pharmacological
delirium prevention strategies

27. Pharmacologic treatment

28. Pharmacologic treatment
Treatment with medication
 if nonpharmacological Strategies cannot
prevent aggression or severe agitation
 if there is sleep-wake disturbance or psychosis

29. Typical and atypical
antipsychotics
 May be considered even though inconclusive
evidence that antipsychotic use reduces
delirium severity or duration.
 For short time, and down-titration or
discontinuation should be considered on a
daily basis.
 Recent studies suggest that antipsychotics are
useful in delirium prophylaxis, particularly in
the postsurgical period.

30. Typical and atypical
antipsychotics

31. Typical and atypical
antipsychotics
Potential side effects :
 Extrapyramidal symptoms (EPS), including
parkinsonism and dystonia
 Prolongation of QT interval, particularly with
haloperidol
 Atypical antipsychotics generally have a lower
propensity to induce EPS, prolonged use in
patients with dementia has been associated
with increased mortality.

32. Home message
 Recognizing delirium promptly and treating the
underlying cause can prevent the significant
consequences of an acute disturbance in
cognition, which include cognitive and
functional decline, falls, and admission to long-
term care.
 Assess for delirium in all older hospitalized
patients: use simple cognitive screening and
the Confusion Assessment Method. Be sure to
get the history or timecourse of any cognitive
changes from an informed proxy.

33.  The presence of delirium may indicate
underlying brain vulnerability and should
therefore increase suspicion for an underlying
cognitive impairment or dementia, especially if
the precipitating insult appears
disproportionately minor.
 Evaluating medications is a high-yield
procedure (the medication list “biopsy”).
Reduce psychoactive medications as a first
step wherever possible.

34.  Primary prevention is the cornerstone of
delirium management and has the best
evidence for success of any intervention.
 Typical and atypical antipsychotics may be
used on an off-label basis for a short time and
if downtitration and discontinuation are
considered on a daily basis.