Delirium is defined as an acute change in attention and cognition with the hallmark pattern of waxing and waning behaviors. Anyboy with a preexisting functional or cognitive impairment is at higher risk for develiping delirium, and the diagnosis of delirium in persons with dementia is commonly missed by clinicians because the presentations are mistakenly perceived as being part of the chronic day-to-day confusion of dementia or attributed to behaviors labeled as sundowning. Dementia increases the risk for delirium, and “sundowning” syndrome is frequently associated solely with dementia.
Delirium occurs in up to 60% of nursing home residents and up to 83% of patients at the end of life. The occurrence of delirium superimposed on dementia is estimated to range between 22% and 89% in older adult populations. Nurses miss about 50% to 60% of delirium cases in the older adults, and the prevalence of delirium in the older hospitalized adults ranges from 10% to 80%. Untreated delirium hampers treatment, increases risk of injury, and contributes to increased length of hospital statys and health care expenses. Patients with delirium have an increased risk of death during the episode and have poorer outcomes after hospitalization when compared with patients without delirium. Cognitive and communication deficits that accompany the syndrome interfere with caregiving and add stress to already burdened families.
A key barrier to managing delirium is lack of recognition. Patients with dementia and multiple illnesses are at highest risks for developing delirium, so caregivers must remain vigilant and suspect delirium whenever there is a new onset or increase in the frequency or severity of cognitive, functional, or behavioral changes that erupt over hours to days. Acute changes from baseline in mental status (with possible fluctuations) and inattention, along with disorganized thinking and/or altered levels of consiousness, should signal further assessments for delirium. Early recognition is imperative to provide interventions that may reverse the underlying causes and improve patient outcomes or simply maintain patients’ safety and comfort.
Delirium is usually multifactorial. Although delirium may have numerous causes, caregivers should begin by investigating common causes such as infections and other intercurrent illnesses, medications [The use of famotidine (Pepcid) has been found to cause delirium in older adults], dehydration, pain, altered laboratory values, sensory alterations due to lack of eyeglasses or hearing airds, and environmental conditions such as sleep deprivation.
There is no one sice fits all approach. Most treatment guidelines focus on treating the underlying cause, decreasing environmental stimuli, and using antipsychotic medications. And based on the patient’s advance directives, underlying causes for delirium, such as infection, may or may not be treated with antibiotics. Regardless of the health care decision options chosen, caregivers must ensure that medthods are used to keep the patient comfortable by utilizing pharmacological and/or nonpharmacological methods.
Delirium may present with one or more motoric subtypes such as hyperactive, hypoactive, or mixed. Patients who demonstrate a recent onset of behaviors that are obvious departures from baseline behaviors, such as increased agitation, hypervigilance, restlessness, wandering, and falling, warrant investigation for a hyperactive delirium. However, the majority of patients present with a hypoactive delirium, which marked by a decrease in cognitive status and motor actitivy and is the most common type of delirium that is missed. It should also be noted that whichever type of delirium a patient experiences, their family is experiencing distress as well. Families of patients at the end of life have spoken of an early bereavement when they feel they have lost the person’s consiousness despite their loved one’s continued physical existence.
Cohen, C. L. (2015) Refractory Delirium in a Hospice Patient – A Case Study
Gallagher, M., & Long, C. O. (2011). Advanced Dementia Care – Demystifying Behaviors, Addressing Pain, and Maximizing Comfort.