PRACTICE RECOMMENDATIONS
• Nonpharmacologic interventions are the mainstay of treatment for delirium. B
• When medication is needed, atypical antipsychotics are as effective as typical antipsychotics for treating delirium in elderly patients, and have fewer side effects. B
• Benzodiazepines should be avoided in elderly patients with delirium that is not associated with alcohol withdrawal. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE Mr. D, a 75-year-old patient with a history of hypertension and congestive heart failure, sustained a femoral neck fracture and was admitted to the hospital for surgery. He underwent open reduction and internal fixation and was doing well postoperatively, until Day 2—when his primary care physician made morning rounds and noted that Mr. D was somnolent. The nurse on duty assured the physician that Mr. D was fine and “was awake and alert earlier,” and attributed his somnolence to the oxycodone (10 mg) the patient was taking for pain. The physician ordered a reduction in dosage.
If Mr. D had been your patient, would you have considered other possible causes of his somnolence? Or do you think the physician’s action was sufficient?
Derived from Latin, the word delirium literally means “off the [ploughed] track.”1 Dozens of terms have been used to describe delirium, with acute confusion state, organic brain syndrome, acute brain syndrome, and toxic psychosis among them.
Delirium has been reported to occur in 15% to 30% of patients on general medical units,2 about 40% of postoperative patients, and up to 70% of terminally ill patients.3 The true prevalence is hard to determine, as up to 66% of cases may be missed.4
Delirium is being diagnosed more frequently, however—a likely result of a growing geriatric population, increased longevity, and greater awareness of the condition. Each year, an estimated 2.3 million US residents are affected, leading to prolonged hospitalization; poor functional outcomes; the development or worsening of dementia; increased nursing home placement; and a significant burden for families and the US health care system.5
Delirium is also associated with an increase in mortality.6,7 The mortality rate among hospitalized patients who develop delirium is reported to be 18%, rising to an estimated 47% within the first 3 months after discharge.6 Greater awareness of risk factors, rapid recognition of signs and symptoms of delirium, and early intervention—detailed in the text and tables that follow—will lead to better outcomes.
Assessing risk, evaluating mental status
In addition to advanced age, risk factors for delirium (TABLE 1)8-14 include alcohol use, brain dysfunction, comorbidities, hypertension, malignancy, anticholinergic medications, anemia, metabolic abnormalities, and male sex. In patients who, like Mr. D, have numerous risk factors, early—and frequent—evaluation of mental status is needed. One way to do this is to treat mental status as a vital sign, to be included in the assessment of every elderly patient.15
The Confusion Assessment Method, a quick and easy-to-use delirium screening tool (TABLE 2), has a sensitivity of 94% to 100% and a specificity of 90% to 95%.16,17 There are a number of other screening tools, including the widely used Mini-Mental State Exam (MMSE), as well as the Delirium Rating Scale, Delirium Symptom Interview, and Delirium Severity Scale.
TABLE 1
Risk factors for delirium8-14
Advanced age Alcohol use Brain dysfunction (dementia, epilepsy) Hypertension Male sex Malignancy Medications (mainly anticholinergic) Metabolic abnormalities:
Old age Preoperative anemia Preoperative metabolic abnormalities |
| BUN, blood urea nitrogen; Cr, creatinine; Na, sodium. |
TABLE 2
Screening for delirium: The Confusion Assessment Method*16,17
| Criteria | Evidence Yes to questions 1, 2, and 3 plus 4 or 5 (or both) suggests a delirium diagnosis |
|---|---|
| 1. Acute onset | Is there evidence of an acute change in mental status from the patient’s baseline? |
| 2. Fluctuating course | Did the abnormal behavior fluctuate during the day—ie, tend to come and go or increase and decrease in severity? |
| 3. Inattention | Did the patient have difficulty focusing attention, eg, being easily distractible or having difficulty keeping track of what was being said? |
| PLUS | |
| 4. 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? |
| 5. Altered level of consciousness | Would you rate the patient’s level of consciousness as (any of the following): – Vigilant (hyperalert) – Lethargic (drowsy, easily aroused) – Stupor (difficult to arouse) – Coma (unarousable) |
| *CAM shortened version worksheet. Adapted from: Inouye SK et al. Clarifying confusion: the Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990;113:941-948; Inouye SK. Confusion Assessment Method (CAM): Training Manual and Coding Guide. Copyright 2003, Hospital Elder Life Program, LLC. | |