Delirium Superimposed on Dementia

  • Ahmet Turan Isik


Delirium and dementia, two common geriatric syndromes, can present with similar symptoms and can share some physiopathological and clinical interrelationship. Delirium superimposed on dementia (DSD) is considered as an acute change in mental status, such as a fluctuating course, inattention, and either disorganized thinking or changes in consciousness that is observed in elderly patients with dementia. DSD tends to have significantly higher mortality risk, more institutionalization, rehospitalization, and cognitive and functional decline than delirium without dementia. DSD is usually underrecognized, misdiagnosed, and undertreated, most generally due to it natural course and behavioral and psychological symptoms. Prevention and treatment of DSD is similar to delirium without dementia, but it is much more important to develop primary and secondary prevention; therefore, keeping close contact with the patient; providing adequate vision, hearing, nutrition, hydration, and sleep; informing the caregivers about delirium to recognize early symptoms; mobilizing the patient as early as possible; and managing the pain are strongly recommended, as well as identifying all underlying medical conditions. If non-pharmacological interventions are considered insufficient, pharmacologic therapy should be implemented.

Clinical features, pathophysiological mechanisms, management, and prognosis of DSD were reviewed in this chapter.


  1. Al-Aama T, Brymer C, Gutmanis I et al (2011) Melatonin decreases delirium in elderly patients: a randomized, placebo-controlled trial. Int J Geriatr Psychiatry 26:687–694CrossRefPubMedGoogle Scholar
  2. Boettger S, Jenewein J, Breitbart W (2014) Delirium in advanced age and dementia: a prolonged refractory course of delirium and lower functional status. Palliat Support Care 13(4):1113–1121CrossRefPubMedPubMedCentralGoogle Scholar
  3. Caplan GA, Lan ZZ, Newton L et al (2014) Transcranial doppler to measure cerebral blood flow in delirium superimposed on dementia. A cohort study. JAMDA 15:355e360Google Scholar
  4. Cerejeira J, Firmino H, Vaz-Serra A et al (2010) The neuroinflammatory hypothesis of delirium. Acta Neuropathol 119:737–754CrossRefPubMedGoogle Scholar
  5. Chong E, Tay L, Chong MS (2015) Identifying phenomenological differences and recovery of cognitive and non-cognitive symptomatology among delirium superimposed upon dementia patients (DsD) versus those without dementia (DaD) in an acute geriatric care setting. Int Psychogeriatr 9:1–11Google Scholar
  6. Davis HJ, Muniz-Terrera G, Keage HAD et al (2017) Association of delirium with cognitive decline in late life: a neuropathologic study of 3 population-based cohort studies. J Am Med Assoc Psychiatry 74:244–251Google Scholar
  7. Francis J, Martin D, Kapoor WN (1990) A prospective study of delirium in hospitalized elderly. JAMA 263(8):1097–1101Google Scholar
  8. Fick D, Agostini JV, Inouye SK (2002) Delirium superimposed on dementia: a systematic review. J Am Geriatr Soc 50:1723–1732CrossRefPubMedGoogle Scholar
  9. Fick DM, Kolanowski A, Waller JL et al (2005) Delirium superimposed on dementia in a community-dwelling managed care population: a 3-year retrospective study of occurrence, costs, and utilization. J Gerontol 60A(6):748–753CrossRefGoogle Scholar
  10. Fick DM, Steis MR, Waller JL et al (2013) Delirium superimposed on dementia is associated with prolonged length of stay and poor outcomes in hospitalized older adults. J Hosp Med 8:500–505CrossRefPubMedPubMedCentralGoogle Scholar
  11. Fong TG, Jones RN, Shi P et al (2009) Delirium accelerates cognitive decline in Alzheimer disease. Neurology 72:1570–1575CrossRefPubMedPubMedCentralGoogle Scholar
  12. Fong TG, Jones RN, Marcantonio ER et al (2012) Adverse outcomes after hospitalization and delirium in persons with Alzheimer disease. Ann Intern Med 156(12):848–856CrossRefPubMedPubMedCentralGoogle Scholar
  13. Gamberini M, Bolliger D, Lurati Buse GA et al (2009) Rivastigmine for the prevention of postoperative delirium in elderly patients undergoing elective cardiac surgery—a randomized controlled trial. Crit Care Med 37(5):1762–1768CrossRefPubMedGoogle Scholar
  14. Gore RL, Vardy ERLC, O’Brien JT (2015) Delirium and dementia with Lewy bodies: distinct diagnoses or part of the same spectrum? J Neurol Neurosurg Psychiatry 86(1):50–59CrossRefPubMedGoogle Scholar
  15. Gross AL, Jones RN, Habtemariam DA et al (2012) Delirium and long-term cognitive trajectory among persons with dementia. Arch Intern Med 172:1324–1331CrossRefPubMedPubMedCentralGoogle Scholar
  16. Hanson MR, Galvez-Jimenez N (2004) Management of dementia and acute confusional states in the perioperative period. Neurol Clin 22:413–422CrossRefGoogle Scholar
  17. Hasegawa N, Hashimoto M, Yuuki S et al (2013) Prevalence of delirium among outpatients with dementia. Int Psychogeriatr 25(11):1877–1883CrossRefPubMedGoogle Scholar
  18. Hofmann M, Schneider D (2007) Practice guidelines for the treatment of patients with delirium. In: Skolnik NS (ed) Current clinical practice: essential practice guidelines in primary care. Humana Press, Totowa, NJ, pp 341–349CrossRefGoogle Scholar
  19. Inouye SK (1998) Delirium in hospitalized older patients. Clin Geriatr Med 14(4):745–765PubMedGoogle Scholar
  20. Inouye SK (2006) Delirium in older persons. N Engl J Med 354:1157–1165CrossRefPubMedGoogle Scholar
  21. Inouye SK, Bogardus ST, Charpentier PA et al (1999) A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 340:669–676CrossRefPubMedGoogle Scholar
  22. Inouye SK, Westendorp RGJ, Saczynski JS (2014) Delirium in elderly people. Lancet 383:911–922CrossRefPubMedGoogle Scholar
  23. Isik AT (2010) Late onset Alzheimer’s disease in older people. Clin Interv Aging 5:307–311CrossRefPubMedPubMedCentralGoogle Scholar
  24. Isik AT (2014) Geriatrik Olgularda Deliryum/Delirium in The Elderly. İzmir Guven Kitap, Izmir, Turkey. isbn:978-605-60355Google Scholar
  25. Kakuma R, du Fort GG, Arsenault L et al (2003) Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc 51:443–450CrossRefPubMedGoogle Scholar
  26. Kalish VB, Gillham JE, Unwin BK (2014) Delirium in older persons: evaluation and management. Am Fam Physician 90(3):150–158PubMedGoogle Scholar
  27. Kennedy GJ (2003) Dementia. In: Cassel CK, Leipzig RM, Cohen HJ, Larson EB, Meier DE (eds) Geriatric medicine: an evidence-based approach, 4th edn. Springer, New York, pp 1079–1093CrossRefGoogle Scholar
  28. Landreville P, Voyer P, Carmichael PH (2013) Relationship between delirium and behavioral symptoms of dementia. Int Psychogeriatr 25:635–643CrossRefPubMedGoogle Scholar
  29. de Lange E, Verhaak PF, van der Meer K (2012) Prevalence, presentation and prognosis of delirium in older people in the population, at home and in long-term care: a review. Int J Geriatr Psychiatry 28:127–134CrossRefPubMedGoogle Scholar
  30. Larsen KA, Kelly SE, Stern TA (2010) Administration of olanzapine to prevent postoperative delirium in elderly joint-replacement patients: a randomized, controlled trial. Psychosomatics 51(5):409–418CrossRefPubMedGoogle Scholar
  31. Leonard MM, Agar M, Spiller JA (2014) Delirium diagnostic and classification challenges in palliative care: subsyndromal delirium, comorbid delirium-dementia, and psychomotor subtypes. J Pain Symptom Manag 48:199–214CrossRefGoogle Scholar
  32. McCusker J, Cole M, Abrahamowicz M et al (2001a) Environmental risk factors for delirium in hospitalized older people. J Am Geriatr Soc 49:1327–1334CrossRefPubMedGoogle Scholar
  33. McCusker J, Cole M, Dendukuri N (2001b) Delirium in older medical inpatients & subsequent cognitive & functional status: a prospective study. CMAJ 165:575–583PubMedPubMedCentralGoogle Scholar
  34. McNicoll L, Pisani MA, Zhang Y et al (2003) Delirium in the intensive care unit: occurrence and clinical course in older patients. J Am Geriatr Soc 51:591–598CrossRefPubMedGoogle Scholar
  35. Moraga AV, Rodriguez-Pascual C (2007) Accurate diagnosis of delirium in elderly patients. Curr Opin Psychiatry 20:262–267CrossRefPubMedGoogle Scholar
  36. Morandi A, Davis D, Fick DM et al (2014) Delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients. JAMDA 15(2014):349–354PubMedPubMedCentralGoogle Scholar
  37. Morandi A, Lucchi E, Turco R et al (2015) Delirium superimposed on dementia: A quantitative and qualitative evaluation of patient experience. J Psychosom Res 79(4):281–287Google Scholar
  38. Morandi A, Davis D, Bellelli G et al (2017) The diagnosis of delirium superimposed on dementia: an emerging challenge. J Am Med Dir Assoc 18(1):12–18CrossRefPubMedGoogle Scholar
  39. National Institute for Health and Care Excellence (2010) Delirium: diagnosis, prevention and managementGoogle Scholar
  40. Pavlov VA, Parrish WR, Rosas-Ballina M et al (2009) Brain acetylcholinesterase activity controls systemic cytokine levels through the cholinergic antiinflammatory pathway. Brain Behav Immun 23:41e45CrossRefGoogle Scholar
  41. Rana AQ, Morren JA (2013) Delirium, neurological emergencies in clinical practice. Springer, London, pp 15–23CrossRefGoogle Scholar
  42. Richardson SJ, Davis DHJ, Bellelli G et al (2017) Detecting delirium superimposed on dementia: diagnostic accuracy of a simple combined arousal and attention testing procedure. Int Psychogeriatr 31:1–9Google Scholar
  43. Robertson B, Blennow K, Gottfries CG et al (1998) Delirium in dementia. Int J Geriatr Psychiatry 13:49–56CrossRefGoogle Scholar
  44. Roden M, Simmons BB (2014) Delirium superimposed on dementia and mild cognitive impairment. Postgrad Med 126(6):129–137CrossRefPubMedGoogle Scholar
  45. Steis MR, Fick DM (2012) Delirium superimposed on dementia: accuracy of nurse documentation. J Gerontol Nurs 38:32–42CrossRefPubMedGoogle Scholar
  46. Tabet N, Howard R (2009) Pharmacological treatment for the prevention of delirium: review of current evidence. Int J Geriatr Psychiatry 24(10)Google Scholar
  47. Trzepacz PT, Mulsant BH, Dew MA (1998) Is delirium different when it occurs in dementia? A study using the delirium rating scale. J Neuropsychiatr Clin Neurosci 10:199–204CrossRefGoogle Scholar
  48. Tucker AM, Stern Y (2011) Cognitive research imaging. Curr Alzheimer Res 8:354–360CrossRefPubMedPubMedCentralGoogle Scholar
  49. Vardi K, Harrington CJ (2014) Delirium: treatment and prevention (part 2). R I Med J 97(6):24–28Google Scholar
  50. Voyer P, Richard S, Doucet L (2011) Factors associated with delirium severity among older persons with dementia. J Neurosci Nurs 43:62–69CrossRefPubMedGoogle Scholar
  51. Wilber ST (2006) Altered mental status in older emergency department patients. Emerg Med Clin North Am 24:299–316CrossRefPubMedGoogle Scholar
  52. Young J, Inouye SK (2007) Delirium in older people. BMJ 334:842–846CrossRefPubMedPubMedCentralGoogle Scholar
  53. Yoon HJ, Park KM, Choi WJ et al (2013) Efficacy and safety of haloperidol versus atypical antipsychotic medications in the treatment of delirium. BMJ Psychiatry 13:240;1–11Google Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Unit for Aging Brain and Dementia, Department of Geriatric Medicine, Faculty of MedicineDokuz Eylul UniversityIzmirTurkey

Personalised recommendations