DELIRIUM:

Acute Confusion in the

Elderly

Donald R. Noll DO FACOI/ edited by Edward Warren, MD, Chair Geriatrics

Carolinas Campus January 2012 revised July 2013

Copyright® 2013
 GOAL
To understand the condition, delirium, to
diagnose it, and to treat it effectively.
 DELIRIUM
• Delirium is a serious disturbance in a person's mental
abilities, often with quick onset, that results in a
decreased awareness of one's environment and
confused thinking.
• IT IS VERY DANGEROUS!
• There are many varied presentations and causes of
delirium. The following slides cover a number of
different common presentations.
 Presentation 1

• An 85 year old woman comes to your office

with vertigo. You diagnose benign positional
vertigo and start meclizine.
• In the next 48 hours she develops progressive
memory loss, confusion, hallucinations and
can no longer take care of herself at home.
• Acute delirium 2° to medication
 Presentation 2

• A 78 year old man with a history of hypertension

and anxiety has a TURP done. He stays
overnight because of somnolence after the
anesthetic, so you hold the lorazepam.
• The next day, you are called to bedside because
of acute shaking, agitation, fast pulse, and an
elevated BP.
• Delirium 2° to lorazepam withdrawal
 Presentation 3

• A 65 year old man with moderate dementia

lives with his daughter. She leaves on a
vacation, and he goes to stay with his son.
• During the first night, he has worsening of
memory and increased confusion with
agitation.
• Delirium 2° the stress of a new place
 Presentation 4

• A 76 year old nursing home patient, debilitated

from prior strokes, becomes anorexic, stops
talking, and becomes lethargic.
• Work-up finds she has many bacteria and
white blood cells in the urine and some supra-
pubic pain.
• Delirium 2° to a UTI
 Presentation 5

• A 70 year old man with no medical problems

rushes out to shovel the new snow from the
driveway, slips, falls, and fractures his hip.
• During the post operative period, he is
confused, disorientated at times, especially
at night. Confusion waxes and wanes.
• Delirium 2° to the surgery/hip fracture
 Delirium Is...

• Common
– One third of hospitalized patients have delirium,
especially the elderly.
• Serious
– It has higher mortality rates, and slows recovery.
– Hospital mortality rate is 22 - 76% (as high as the rates
for myocardial infarction or sepsis).
– One year mortality is 35 - 40%.
• Unrecognized
– 32 – 67% percent of cases are missed.
A Study of Delirium in Nursing Homes

• 23% had delirium

• One week after admission, status of delirium
– 14% recovered 52% no change
– 22% better 12% worse
• Delirium was associated with significantly worse recovery in
ADL’s and IADL’s

This study illustrates delirium is very common on rehab units and Skilled Nursing Units
(where patients are often discharged to from acute care). Some get worse, some better, but
it has a negative impact on recovery.
 Delirium Predicts Worse
12 Month Mortality

• A prospective, observational study of 2 cohorts, of

patients  65 years old
– 243 patients with hospital delirium and 118 matched controls
• Adjusted hazard ratio 2.11, (C.I., 1.18-3.77)
– twice as likely to die in the next year
• Effect stronger in patients without dementia
• Worse symptoms  higher mortality!
 The duration of Delirium
 Delirium is an considered an acute condition, but it may
take as long as four to six weeks for a patient to return to
their previous cognitive baseline and make a full recovery.
 Many persons with underlying dementia, never return to
their previous functional or cognitive level after an episode
of delirium.
 If the underlying condition that is causing the delirium is
not corrected, then the state of delirium can continue
indefinitely, and become a “chronic” delirium.
 Terms for the same thing

• Delirium
There are many terms for
• Acute confusion delirium, which may cause
some confusion. These terms
• Acute confusional state all refer to the same condition.

• Metabolic encephalopathy
• Toxic encephalopathy
• Acute brain syndrome
• Brain Failure
Clinical Characteristics of
Delirium
Delirium: A Disorder of Attention
• Reduced ability to maintain attention to
external stimuli
– attention wanders
– have to ask the question again
• Can not shift attention
– perseverates (repeats answer to prior question)
• Disorganized thinking, speech rambling,
irrelevant, or incoherent
 Delirium: Clinical Features
(Usually at least two present)

• Reduced level of consciousness

• Perceptual disturbance (hallucinations)
• Disrupted sleep wake cycle
• Increased or decreased psychomotor activity
• Disorientation to time, place and person
• Memory impairment
 Delirium: More clinical features
(Acute, waxes/wanes)

• Clinical features develop over a short period

of time (hours to days)
• Clinical feature fluctuates of the coarse of the
day
– waxes and wanes
– medical student sees in AM, doing well, then
attending sees in afternoon, doing very differently
 Delirium: More clinical features
(History and Causation)

• The history, physical or lab tests will

usually show some organic or medical
cause
• No functional disorder, (bipolar disorder,
schizophrenia)
 DSM-IV Criteria for Delirium
• Disturbance of consciousness: can’t focus,
can’t sustain, or can’t shift attention
• Change in cognition: memory, orientation,
language or perceptual disturbance
• Disturbance develops over a short time and
fluctuates
• History, physical, tests point to a physiologic
cause
 The Confusion Assessment Method (CAM)
• The CAM algorithm is based on the presence of
the features of acute onset and fluctuating course,
inattention, and either disorganized speech or
altered level of consciousness.
• For diagnosis of delirium, it has a
– sensitivity of 94% to 100%,
– specificity of 90% to 95%,
– positive predictive accuracy of 91% to 94%,
– negative predictive accuracy of 90% to 100%
 The Confusion Assessment Method (CAM) *
• The original CAM study had 9 parts. Only
the first 4 were found to have statistical
significance for delirium.
• Scoring requires the first 2 features and one
of the last 2 features for a positive diagnosis.
 Original criteria
1.  [Acute Onset] Is there evidence of an acute change in mental status from the patient's baseline?
2A.  [Inattention] Did the patient have difficulty focusing attention, for example, being easily distractible, or having
difficulty keeping track of what was being said?
2B.  (If present or abnormal) Did this behavior fluctuate during the interview, that is, tend to come and go or increase and
decrease in severity?
3.  [Disorganized thinking] Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant
conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
4.  [Altered level of consciousness] Overall, how would you rate this patient's level of consciousness? (Alert [normal];
Vigilant [hyperalert, overly sensitive to environmental stimuli, startled very easily], Lethargic [drowsy, easily aroused];
Stupor [difficult to arouse]; Coma; [unarousable]; Uncertain)
5.  [Disorientation] Was the patient disoriented at any time during the interview, such as thinking that he or she was
somewhere other than the hospital, using the wrong bed, or misjudging the time of day?
6.  [Memory impairment] Did the patient demonstrate any memory problems during the interview, such as inability to
remember events in the hospital or difficulty remembering instructions?
7.  [Perceptual disturbances] Did the patient have any evidence of perceptual disturbances, for example, hallucinations,
illusions or misinterpretations (such as thinking something was moving when it was not)?
8A.  [Psychomotor agitation] At any time during the interview did the patient have an unusually increased level of motor
activity such as restlessness, picking at bedclothes, tapping fingers or making frequent sudden changes of position?
8B.  [Psychomotor retardation]. At any time during the interview did the patient have an unusually decreased level of motor
activity such as sluggishness, staring into space, staying in one position for a long time or moving very slowly?
9.  [Altered sleep-wake cycle]. Did the patient have evidence of disturbance of the sleep-wake cycle, such as excessive
daytime sleepiness with insomnia at night?
 Confusion Assessment Method (CAM)
Feature 1: Acute Onset and Fluctuating Course
This feature is usually obtained from a family member or nurse and is shown by positive
responses to the following questions: Is there evidence of an acute change in mental status
from the patient's baseline? Did the (abnormal) behavior fluctuate during the day; that is, did it
tend to come and go, or increase and decrease in severity?

Feature 2: Inattention
This feature is shown by a positive response to the following question: Did the patient have
difficulty focusing attention; for example, being easily distractible, or having difficulty keeping
track of what was being said?

Feature 3: Disorganized Thinking

This feature is shown by a positive response to the following question: Was the patient's
thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or
illogical flow of ideas, or unpredictable switching from subject to subject?

Feature 4: Altered Level of Consciousness

This feature is shown by any answer other than "alert" to the following question: Overall, how
would you rate this patient's level of consciousness? (alert [normal], vigilant [hyperalert],
lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousabe]
 Two Basic Types of Delirium
D e lir iu m

H y p e r v ig ila n t H y p e rs o m n o le n t
(m o re o fte n ) (m o re o fte n )
A lc o h o l u n r e c o g n iz e d
D ru g s m any causes

An acute change in mental status (delirium), can present as an excited, hyper-

sympathetic state (fast heart rate, tremors) or as an obtunded, sleepy patient, or
as a mixture of both.
Types of Delirium

14% 15%

Hyperactive
19% Hypoactive
Mixed
52% No pattern
Key Concepts
 Key to understanding delirium

+ Stress = Heart
Failure

+ Stress = Brain
Failure
Delirium is similar to heart failure. Given enough stress or metabolic
demand, any heart or brain will fail to keep up with demand.
 Heart/Brain Failure more likely to occur
with baseline damage

+ Stress = Heart
Failure

+ Stress = Brain
Failure
A damaged brain is much more vulnerable to failure. With Parkinson’s Disease, a closed head
injury, or dementia, one is more likely to suffer delirium when exposed to a physiologic stress.
 The metabolism/threshold model

• Animal studies and imaging studies show a

deranged cortical glucose metabolism.
• Cerebral metabolic insufficiency is the
underlying mechanism.
• After multiple cortical insults, “cortical reserves”
are depleted, triggering global metabolic
insufficiency.
• Pushed over the threshold.
 Cholinergic Model

• Disturbances in cholinergic transmission is

consistently implicated.
• Atropine induces delirium in animal models.
• The elderly have depleted acetylcholine
• Alzheimer’s patients have depleted acetylcholine.
• Anticholinergic medications induce delirium (other
neurotransmiters also important).
 Anti-cholinergic Effects in
Atropine Equivalents

• Furosemide = 0.22
• Digoxin = 0.25
• Theophylline = 0.44
• Cimetidine = 0.86
• Ranitidine = 0.22
• Nifedipine = 0.22
• Warfarin = 0.12
Common causes of delirium
Delirium in the Emergency Room
Age > 70, Seventy-two consecutive cases;
2 reviewers 87.6% agreement.

40
In fe c tio n s
30
d ru g to xic ity
With d ra w a l
20
S e n s o ry
Me ta b o lic
10
In tra c ra in ia l
0

This study illustrates the types of causes of delirium seen in a typical ER. Note the diagnosis of delirium is
somewhat objective, thus the 87.6% agreement between two reviewers – which is fairly good agreement.

JAGS: Sept. 1999, 47;9,S10 (abstract A34)

 Metabolic or Endocrine

• Electrolytes (especially Na, K, Ca)

• Hyperglycemia or hypoglycemia
• Hypoxia or hypercapnea
• Liver or kidney failure
• Thyroid disorder
• Fever
 Infections

• Pneumonia
• Sepsis
• UTI
• URI
 Drug Toxicity

• Anticholinergics
• Neuroleptics or tricyclic antidepressants
• Lithium
• Steroids
• Drug and alcohol withdrawal
Central Nervous system insults

• Seizures: postictal states and

electroconvulsive therapy
• Raised intracrainial pressure
• Head trauma
• Encephalitis, meningitis
• Vasculitis
Treatment and Management
 Nonpharmacologic Management
• Nonpharmacologic approaches should be used for management of every delirious patient. These
approaches include
• strategies for reorientation
• behavioral intervention, such as ensuring the presence of family members
• orienting influences
• use of sitters
• transferring a disruptive patient to a private room or closer to the nurse's station for increased
supervision.
• Personal contact and communication are critical, incorporating reorientation strategies, simple
instructions, and frequent eye contact.
• Patients should be encouraged to participate in decision making about their care as much as
possible.
• Eyeglasses and hearing aids (if needed) should be worn as much as possible to reduce sensory
deficits.
 Nonpharmacologic Management
• Mobility
• Self-care
• Independence should be enhanced
• Physical restraints should be avoided because of their adverse effects
• of immobility
• increased agitation
• potential to cause injury.
• Clocks, calendars, and the day's schedule should be provided to assist with
orientation.
• Room and staff changes should be kept to a minimum.
• A quiet environment with low-level lighting is optimal for the delirious patient.
Nonpharmacologic Management
• Allowing an uninterrupted period for sleep at night is important.
• Ensure a low level of noise at night, including hallway noise and
conversations.
• This requires coordination and scheduling of nursing and medical
procedures, such as
• Medications
• vital signs
• intravenous fluids
• treatments
• Nonpharmacologic approaches for relaxation, including music, relaxation tapes,
and massage
 In managing delirium, you should…

Avoid Restraints whenever Keep them in a well lit

possible, try the least room, at night keep a night
restrictive measures. light on. Avoid over-
Restraints can exacerbate stimulation. It is helpful to
combativeness and have familiar people
agitation. Only use as a around, like family
last resort, when agitation members to reorient them.
prevents vital therapy, like
IV antibiotic and essential
IV fluids.
 Psychological management

• A large calendar and clock in the room

• Family/staff reorient patient frequently
• Familiar things (don’t move rooms)
• Glasses, hearing aids:
 Treatment limitations
• Other than…
– Supportive care
– Address the cause
– Don’t exacerbate the delirium
• No medication or specific intervention has
been shown to improve outcomes
 Pharmacological Management of
Delirium
• Low dose neuroleptics or new “atypicals”
– Haloperidol still the drug of choice
• Benzodiazipines another option
• Re-evaluate daily
• Supportive care (IV fluids if needed)
• Acetlycholinesterace inhibitors might help
 Pharmacologic Management
1. Benzodiazepines are not recommended for treatment of
delirium because they cause
1. oversedation
2. respiratory depression
3. exacerbation of the confusional state.
2. For geriatric patients, lorazepam (starting dose, 0.5-1.0 mg)
is the recommended agent of this class, because of its
1. favorable half-life (10-15 h)
2. lack of active metabolites
3. availability of a parenteral form.
 Antipsychotics
If parenteral administration is required
• Parenteral haloperidol results in
– rapid onset of action
– with short duration of effect
– intramuscular use will have a more optimal duration of action.
• The recommended starting dose of haloperidol is 0.5 to 1.0 mg
orally or parenterally, repeating the dose every 20 to 30 min after
vital signs have been checked, until sedation has been achieved.
• The endpoint should be an awake but manageable patient, not a
sedated patient.
 Antipsychotics
The average elderly patient who has not previously been
treated with neuroleptics should require
– a total loading dose not exceeding 3 to 5 mg
haloperidol.
– a maintenance dose of one-half the loading dose
should be administered in divided doses over the next
24 h
– tapering doses over the next few days.
 Haloperidol
The leading side effects of haloperidol include
• Sedation
• Hypotension
• acute dystonias
• extrapyramidal side effects
• anticholinergic effects (e.g.)
– anticholinergic delirium
– dry mouth
– constipation
– urinary retention
 Conclusions

• Delirium is common, serious and often

overlooked.
• Disturbed consciousness, change in cognition,
acute onset, fluctuating course.
• Remember “Brain Failure”.
• It usually is multi-factorial, many potential causes.
• Treat the cause and give supportive care.
The End…