![]() ![]() ![]() Exceptions can be found, however, including Lewy body dementia, which has fluctuations in cognition as one of the cardinal features. Unlike the rapid onset of delirium, the onset of dementia is usually insidious and not associated with fluctuations in mental state. Recurrent delirium should raise the index of suspicion for dementia. How do I know my patient doesn’t have dementia or depression or both?ĭementia is the most likely predisposing factor for delirium. Others may manifest initially with hypersensitivity to environmental stimuli and hypervigilance, which progress to acute anxiety and then paranoia. Some English-as-a-second-language patients may lose their ability to communicate in English. In geriatric delirium, more subtle manifestations include new-onset incontinence, falls or refusal to mobilize, dysphagia, dysarthria, mild disorientation, and slowing in the speed of mental processing. ![]() And although sleep-wake disturbance is the norm, some delirious patients do sleep well. Apathetic delirium can look like depression. Not all delirious patients present with agitation (hyperactive subtype), however some present with apathy (hypoactive subtype) instead. It is helpful to ask about the patient’s perception of their caregivers (i.e., paranoia regarding them), the presence of vivid dreams or nightmares, and sleep quality of the previous night, although some patients will have little recollection of being symptomatic the night before.Īnxiety and transient mood disturbances can manifest. This fluctuation means that a patient assessed in the daytime may show no signs of delirium the same patient may be quite different in the evening because of the nocturnal worsening (sundowning) that commonly occurs in delirium.Ĭonversely, the patient may seem fine if drowsy in the morning, leading to the erroneous assumption that a dose of sedative administered in the middle of the night is the cause, when in fact the sedative was needed because of insomnia associated with nocturnal agitation or aggression.Īssociated features that are helpful in distinguishing delirium from dementia include new-onset visual illusions or hallucinations, certain agitated behaviors (disrobing, “picking at the air”), and distractibility or poor attention during assessment. The hallmarks of delirium are an acute onset in disturbances of consciousness and attention followed by a fluctuating course. Usually, however, diagnosis requires 24 hours so that caregiver observations (e.g., nursing notes, comments of family members) can be taken into account and any acute change from baseline cognition, function, and/or behaviors can be considered. Detailed management of alcohol withdrawal delirium7 and management of delirium in ICU8 and palliative care settings9 is beyond the scope of this article.ĭelirium is diagnosed according to DSM-IV-TR criteria, and can sometimes be diagnosed at the bedside. Managing geriatric delirium requires differentiating it from other conditions using contemporary educational resources for practitioners, patients, and family members. Using physical restraints alone for management is not appropriate as it can worsen delirium, can contribute to further decline, does not address distressing psychiatric symptoms that are treatable, and is potentially life threatening. When only the physical conditions are treated and the psychiatric manifestations are not addressed (e.g., sleep-wake reversal), the delirium perpetuates and higher morbidity (e.g., deconditioning) and mortality may result. Underdiagnosis can be even more problematic in residential care facilities. Delirium is underrecognized in 32% to 66% of cases, especially in patients 80 years or older and those already experiencing dementia, a hypoactive (apathetic) subtype of delirium, or concomitant visual impairment. The prompt diagnosis and management of delirium is especially important in seniors. However, in most cases the core features of delirium allow for recognition. This can be challenging clinically, especially when such mental conditions occur concurrently. Often referred to as “confusion” by health professionals and the lay public alike, the term “delirium” is more specific and should be used to distinguish between this acute condition and other geriatric syndromes such as dementia. A substantial number of patients are delirious upon admission or later develop delirium during the course of hospitalization.ĭelirium is usually triggered by acute medical or surgical illness, or by certain medications. Delirium is a psychiatric and medical emergency with rates as high as 50% in older hospitalized patients. ![]()
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