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Delirium in Older Adults

  • Ana Hategan
  • Calvin H. Hirsch
  • Deborah Francis
  • James A. Bourgeois
Chapter

Abstract

Delirium is one of the most serious medical complications experienced by older patients. Emphasis on early recognition, prevention, and management of delirium underlines the need for effective services across multiple settings from community to hospitals and other institutional care settings. At present, the diagnosis of delirium is clinically based. Management strategies for delirium need to be focused on prevention and symptom management. This chapter reviews the etiology, consequences, screening, diagnosis, prevention, and management of delirium in older patients.

Keywords

Delirium in older adults Geriatric delirium Confusion Neurocognitive disorder Delirium prevention Delirium prophylaxis 

References

  1. 1.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.CrossRefGoogle Scholar
  2. 2.
    World Health Organization. The ICD-10 classification of mental and behavioural disorders. Diagnostic criteria for research. Geneva, Switzerland: WHO; 1993.Google Scholar
  3. 3.
    Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol. 2009;5(4):210–20.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Inouye SK. Delirium in older persons. N Engl J Med. 2006;354(11):1157–65.CrossRefPubMedGoogle Scholar
  5. 5.
    Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing. 2006;35(4):350–64.CrossRefPubMedGoogle Scholar
  6. 6.
    Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med. 2009;16:193–200.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Spronk PE, Riekerk B, Hofhuis J, et al. Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med. 2009;35(7):1276–80.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Jones SF, Pisani MAICU. delirium: an update. Curr Opin Crit Care. 2012;18(2):146–51.CrossRefPubMedGoogle Scholar
  9. 9.
    Lawlor PG, Gagnon B, Mancini IL, et al. Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Arch Intern Med. 2000;160(6):786–94.CrossRefPubMedGoogle Scholar
  10. 10.
    Ganzini L. Care of patients with delirium at the end of life. Annals of Long-Term Care. 2007;15(3):35–40.Google Scholar
  11. 11.
    Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911–22.CrossRefPubMedGoogle Scholar
  12. 12.
    Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive Care Med. 2007;33:66–73.CrossRefPubMedGoogle Scholar
  13. 13.
    Ahmed S, Leurent B, Sampson EL. Risk factors for incident delirium among older people in acute hospital medical units: a systematic review and meta-analysis. Age Ageing. 2014;43(3):326–33.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis and treatment. Crit Care Clin. 2008;24(4):657–722, vii.CrossRefPubMedGoogle Scholar
  15. 15.
    Laurila JV, Laakkonen ML, Tilvis RS, Pitkala KH. Predisposing and precipitating factors for delirium in a frail geriatric population. J Psychosom Res. 2008;65:249–54.CrossRefPubMedGoogle Scholar
  16. 16.
    Davis DHJ, Muniz Terrera G, Keage H, et al. Delirium is a strong risk factor for dementia in the oldest-old: a population-based cohort study. Brain. 2012;135(9):2809–16.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Meagher DJ, Trzepacz PT. Motoric subtypes of delirium. Sem. Clin Neuropsychiatry. 2000;5:75–85.Google Scholar
  18. 18.
    Marcantonio ER, Ta T, Duthie E, et al. Delirium severity and psychomotor types: their relationship with outcomes after hip fracture repair. Am J Geriatr Soc. 2002;50:850–9.CrossRefGoogle Scholar
  19. 19.
    Rabinowitz T. Delirium. An important (but often unrecognized) clinical syndrome. Curr Psychiatry Rep. 2002;4:202–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Meagher D, O’Regan N, Ryan D, et al. Frequency of delirium and subsyndromal delirium in an adult acute hospital population. Br J Psychiatry. 2014;205(6):478–85.CrossRefPubMedGoogle Scholar
  21. 21.
    Sepulveda E, Leonard M, Franco JG, et al. Subsyndromal delirium compared with delirium, dementia, and subjects without delirium or dementia in elderly general hospital admissions and nursing home residents. Alzheimers Dement (Amst). 2017;7:1–10.Google Scholar
  22. 22.
    Meagher D, Adamis A, Trzepacz P, Leonard M. Features of subsyndromal and persistent delirium. Br J Psychiatry. 2012;200:37–44.CrossRefPubMedGoogle Scholar
  23. 23.
    Cole MG, McCusker J, Voyer P, et al. Subsyndromal delirium in older long-term care residents: incidence, risk factors, and outcomes. J Am Geriatr Soc. 2011;59:1829–36.Google Scholar
  24. 24.
    Robinson TN, Raeburn CD, Tran ZV, Brenner LA, Moss M. Motor subtypes of postoperative delirium in older adults. Arch Surg. 2011;146(3):295–300.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Meagher DJ, Leonard M, Donnelly S, Conroy M, Adamis D, Trzepacz PTA. Longitudinal study of motor subtypes in delirium: relationship with other phenomenology, etiology, medication exposure and prognosis. J Psychosom Res. 2011;71(6):395–403.CrossRefPubMedGoogle Scholar
  26. 26.
    Albrecht JS, Marcantonio ER, Roffey DM, et al. Stability of postoperative delirium psychomotor subtypes in individuals with hip fracture. J Am Geriatr Soc. 2015;63(5):970–6.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Meagher DJ, Moran M, Raju B, et al. Motor symptoms in 100 patients with delirium versus control subjects: comparison of subtyping methods. Psychosomatics. 2008;49:300–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Ross CA, Peyser CE, Shapiro I, et al. Delirium: phenomenologic and etiologic subtypes. Int Psychogeriatr. 1991;3:135–47.CrossRefPubMedGoogle Scholar
  29. 29.
    Leonard M, Donnelly S, Conroy M, et al. Phenomenological and neuropsychological profile across motor variants of delirium in a palliative-care unit. J Neuropsychiatry Clin Neurosci. 2011;23:180–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Johnson MH. Assessing confused patients. J Neurol Neurosurg Psychiatry. 2001;71:i7–i12.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Meagher DJ, Moran M, Raju B, et al. Phenomenology of delirium: assessment of 100 adult cases using standardized measures. Br J Psychiatry. 2007;190:135–41.CrossRefPubMedGoogle Scholar
  32. 32.
    Charlton BG, Kavanau JL. Delirium and psychotic symptoms: an integrative model. Med Hypotheses. 2002;58:24–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Mittal D, Majithia D, Kennedy R, et al. Differences in characteristics and outcome of delirium as based on referral patterns. Psychosomatics. 2006;47:367–75.CrossRefPubMedGoogle Scholar
  34. 34.
    Cook IA. Guideline watch: practice guideline for the treatment of patients with delirium. Arlington: American Psychiatric Association; 2004. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/delirium-watch.pdf. Accessed 26 May, 2017.Google Scholar
  35. 35.
    Canadian Coalition for Seniors’ Mental Health. In Hogan (ed.) National guidelines for seniors’ mental health: The assessment and treatment of delirium. Toronto: Canadian Government Printing Office; 2006. http://ccsmh.ca/wp-content/uploads/2016/03/NatlGuideline_Delirium.pdf. Accessed 26 May, 2017.
  36. 36.
    Leentjens AF, Diefenbacher AA. Survey of delirium guidelines in Europe. J Psychosom Res. 2006;61:123–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Tropea J, Slee JA, Brand CA, et al. Clinical practice guidelines for the management of delirium in older people in Australia. Australas J Ageing. 2008;27:150–6.CrossRefPubMedGoogle Scholar
  38. 38.
    Gugger JJ, Wagner ML. Rapid eye movement sleep behaviour disorder. Ann Pharmacother. 2007;41(11):1833–41.CrossRefPubMedGoogle Scholar
  39. 39.
    Chédru F, Geschwind N. Writing disturbances in acute confusional states. Neuropsychologia. 1972;10(3):343–53.CrossRefPubMedGoogle Scholar
  40. 40.
    Beglinger LJ, Mills JA, Vik SM, et al. The neuropsychological course of acute delirium in adult hematopoietic stem cell transplantation patients. Arch Clin Neuropsychol. 2011;26(2):98–109.CrossRefPubMedGoogle Scholar
  41. 41.
    Adamis D, Sharma N, Whelan PJ, Macdonald AJ. Delirium scales: a review of current evidence. Aging Ment Health. 2010;14(5):543–55.CrossRefPubMedGoogle Scholar
  42. 42.
    Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113:941–8.CrossRefPubMedGoogle Scholar
  43. 43.
    Fick DM, Agostini JV, Inouye SK. Delirium superimposed on dementia: a systematic review. J Am Geriatr Soc. 2002;50:1723–32.CrossRefPubMedGoogle Scholar
  44. 44.
    Morandi A, Davis D, Fick DM, et al. Delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients. J Am Med Dir Assoc. 2014;15(5):349–54.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Boorsma M, Joling KJ, Frijters DH, Ribbe ME, Nijpels G, van Hout HP. The prevalence, incidence and risk factors for delirium in Dutch nursing homes and residential care homes. Int J Geriatr Psychiatry. 2012;27(7):709–15.CrossRefPubMedGoogle Scholar
  46. 46.
    Kat MG, Vreeswijk R, de Jonghe JF, et al. Long-term cognitive outcome of delirium in elderly hip surgery patients. A prospective matched controlled study over two and a half years. Dement Geriatr Cogn Disord. 2008;26:1–8.CrossRefPubMedGoogle Scholar
  47. 47.
    Fong TG, Jones RN, Shi P, et al. Delirium accelerates cognitive decline in Alzheimer disease. Neurology. 2009;72:1570–5.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Wacker P, Nunes PV, Cabrita H, et al. Postoperative delirium is associated with poor cognitive outcome and dementia. Dement Geriatr Cogn Disord. 2006;21:221–7.CrossRefPubMedGoogle Scholar
  49. 49.
    Meagher DJ, Leonard M, Donnelly S, et al. A comparison of neuropsychiatric and cognitive profiles in delirium, dementia, comorbid delirium–dementia and cognitively intact controls. Neurol Neurosurg Psychiatry. 2010;81:876–81.CrossRefGoogle Scholar
  50. 50.
    Dubin WR, Weiss KJ, Zeccardi JA. Organic brain syndrome. The psychiatric imposter. JAMA. 1983;249:60–2.CrossRefPubMedGoogle Scholar
  51. 51.
    Jacobson S, Jerrier H. EEG in delirium. Semin Clin Neuropsychiatry. 2000;5(2):86–92.PubMedGoogle Scholar
  52. 52.
    Vijayakrishnan R, Ramasubramanian A, Dhand S. Utility of head CT scan for acute inpatient delirium. Hosp Top. 2015;93(1):9–12.CrossRefPubMedGoogle Scholar
  53. 53.
    Balogun SA, Philbrick JT. Delirium, a symptom of UTI in the elderly: fact or fable? A systematic review. Can Geriatr J. 2014;17(1):22–6.CrossRefPubMedGoogle Scholar
  54. 54.
    Milisen K, Lemiengre J, Braes T, Foreman MD. Multicomponent intervention strategies for managing delirium in hospitalized older people: systematic review. J Adv Nurs. 2005;52(1):79–90.CrossRefPubMedGoogle Scholar
  55. 55.
    Yue J, Tabloski P, Dowal SL, Puelle MR, Nandan R, Inouye SKNICE. To HELP: operationalizing National Institute for Health and Clinical Excellence guidelines to improve clinical practice. J Am Geriatr Soc. 2014;62(4):754–61.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Siddiqi N, Harrison JK, Clegg A, Teale EA, Young J, Taylor J, Simpkins SA. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2016;(3):CD005563.Google Scholar
  57. 57.
    Deschodt M, Braes T, Flamaing J, et al. Preventing delirium in older adults with recent hip fracture through multidisciplinary geriatric consultation. J Am Geriatri Soc. 2012;60(4):733–9.CrossRefGoogle Scholar
  58. 58.
    American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. J Am Geriatr Soc. 2015;63(1):142–50.CrossRefGoogle Scholar
  59. 59.
    Martinez F, Tobar C, Hill N. Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature. Age Ageing. 2015;44:196–204.CrossRefPubMedGoogle Scholar
  60. 60.
    Hirsch CH, Maharaj M, Bourgeois JA. The chief adverse effects of medications. In: Hategan A, Bourgeois JA, Hirsch CH, editors. On-call geriatric psychiatry: handbook of principles and practice. Switzerland: Springer; 2016. p. 161–83.Google Scholar
  61. 61.
    American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227–46.Google Scholar
  62. 62.
    Davis MP, Srivastava M. Demographics, assessment and management of pain in the elderly. Drugs Aging. 2003;20(1):23–57.CrossRefPubMedGoogle Scholar
  63. 63.
    Hanania M, Kitain E. Melatonin for treatment and prevention of postoperative delirium. Anesth Analg. 2002;94(2):338–9.PubMedGoogle Scholar
  64. 64.
    Fok MC, Sepehry AA, Frisch L, Sztramko R, Borger van der Burg BL, Vochteloo AJ, et al. Do antipsychotics prevent postoperative delirium? A systematic review and meta-analysis. Int J Geriatr Psychiatry. 2015;30(4):333–44.CrossRefPubMedGoogle Scholar
  65. 65.
    Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc. 2005;53(10):1658–66.CrossRefPubMedGoogle Scholar
  66. 66.
    Neufeld KJ, Yue J, Robinson TN, Inouye SK, Needham DM. Antipsychotic medication for prevention and treatment of delirium in hospitalized adults: a systematic review and meta-analysis. J Am Geriatr Soc. 2016;64(4):705–14.CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Tampi RR, Tampi DJ, Ghori AK. Acetylcholinesterase Inhibitors for Delirium in Older aAdults. Am J Alzheimers Dis Other Demen. 2016;31(4):305–10.CrossRefPubMedGoogle Scholar
  68. 68.
    Youn YC, Shin HW, Choi BS, Kim S, Lee JY, Ha YC. Rivastigmine patch reduces the incidence of postoperative delirium in older patients with cognitive impairment. Int J Geriatr Psychiatry. 2017;32(10):1079–84.Google Scholar
  69. 69.
    de Jonghe A, van Munster BC, Goslings JC, Kloen P, van Rees C, Wolvius R, et al. Effect of melatonin on incidence of delirium among patients with hip fracture: a multicentre, double-blind randomized controlled trial. CMAJ. 2014;186(14):E547–56.CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    Al-Aama T, Brymer C, Gutmanis I, Woolmore-Goodwin SM, Esbaugh J, Dasgupta M. Melatonin decreases delirium in elderly patients: a randomized, placebo-controlled trial. Int J Geriatr Psychiatry. 2011;26(7):687–94.CrossRefPubMedGoogle Scholar
  71. 71.
    Maldonado JR, Wysong A, van der Starre PJ, et al. Dexmedetomidine and the reduction of postoperative delirium after cardiac surgery. Psychosomatics. 2009;50(3):206–17.CrossRefPubMedGoogle Scholar
  72. 72.
    Short J. Use of dexmedetomidine for primary sedation in a general intensive care unit. Crit Care Nurse. 2010;30(1):29–38; quiz 39CrossRefPubMedGoogle Scholar
  73. 73.
    Chen CC, Saczynski J, Inouye SK. The modified Hospital Elder Life Program: Adapting a complex intervention for feasibility and scalability in a surgical setting. J Gerontol Nurs. 2014;40:16–22.CrossRefPubMedGoogle Scholar
  74. 74.
    Buter TC, van den Hout A, Matthews FE, Larsen JP, Brayne C, Aarsland D. Neurology. 2008;70(13):1017–22.CrossRefPubMedGoogle Scholar
  75. 75.
    Hely MA, Reid WG, Adena MA, Halliday GM, Morris JG. The Sydney multicenter study of Parkinson’s disease: the inevitability of dementia at 20 years. Mov Disord. 2008;23(6):837–44.CrossRefPubMedGoogle Scholar
  76. 76.
    Seitz DP, Gill SS. Neuroleptic malignant syndrome complicating antipsychotic treatment of delirium or agitation in medical and surgical patients: case reports and a review of the literature. Psychosomatics. 2009;50(1):8–15.CrossRefPubMedGoogle Scholar
  77. 77.
    Brown AS, Rosen J. Lithium-induced delirium with therapeutic serum lithium levels: a case report. J Geriatr Psychiatry Neurol. 1992;5:53–5.PubMedGoogle Scholar
  78. 78.
    Alexopoulos GS, Streim J, Carpenter D. Docherty JP; Expert Consensus Panel for using Antipsychotic Drugs in Older Patients. Using antipsychotic agents in older patients. J Clin Psychiatry. 2004;65(Suppl 2):5–99; discussion 100–2; quiz 103–4PubMedGoogle Scholar
  79. 79.
    Granja C, Gomes E, Amaro A, et al. Understanding posttraumatic stress disorder-related symptoms after critical care: the early illness amnesia hypothesis. Crit Care Med. 2008;36(10):2801–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Ana Hategan
    • 1
  • Calvin H. Hirsch
    • 2
  • Deborah Francis
    • 3
  • James A. Bourgeois
    • 4
  1. 1.Department of Psychiatry and Behavioural NeurosciencesMcMaster UniversityHamiltonCanada
  2. 2.Division of General MedicineUniversity of California Davis Medical CenterSacramentoUSA
  3. 3.Kaiser Permanente South Sacramento Medical CenterSacramentoUSA
  4. 4.Baylor Scott and White Department of PsychiatryTexas A&M University College of MedicineTempleUSA

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