Delirium is a medical emergency in older adults and is frequently misdiagnosed as dementia. While people with dementia are at a higher risk of delirium, studies have shown that it’s preventable in 30 to 40% of cases and treatable when detected early.
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Delirium is often not recognized and misdiagnosed as dementia, even in the acute care setting.
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The confusion associated with delirium develops in a few hours or days. Cognitive decline associated with dementia develops over months or years.
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Studies show that delirium is preventable in 30-40% of all cases.
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Early recognition of delirium and treatment of its cause will reduce the risk of severe illness or death.
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Maximizing lifestyle habits for older adults can prevent deficiencies that can lead to delirium.
A delay or lack of treatment may result in medical complications, coma, and possibly death. Unfortunately, delirium is often underrecognized, even in the acute clinical setting. Knowing the causes of delirium and how it differs from dementia can be lifesaving in older adults with a sudden onset of confusion.
John’s story
"My dad is in the hospital. He fell at home, and he's so confused. It looks like he has dementia now, but I don't understand. He was fine last week. But he won't be able to live alone anymore! I don’t see any hope.”
John (not his real name) sat before me, distressed that his world had changed so quickly. But did John’s 81-year-old father have dementia, or could it be delirium?
What is delirium?
Delirium isn’t just one disease but a syndrome of abrupt changes in mental status. Sometimes referred to as acute brain failure, symptoms often develop over one or two days. Frequently confusion will vary, where the person with delirium will appear normal and then seem confused a few hours later. This sudden onset and fluctuation in symptoms are classic signs of delirium. A person with delirium may be sleepy and depressed (hypoactive delirium) or agitated and restless (hyperactive delirium).
What is dementia?
Dementia is a neurodegenerative condition that usually develops and progresses over months or years. Dementia is a broad term describing a group of symptoms leading to an overall progressive decline affecting a person's memory and daily function. However, delirium does occur more frequently in people with dementia due to impaired brain function. In addition, because of this diminished function, there can be worse long-term outcomes including further cognitive impairment.
Ten common causes of delirium in older adults
1. Hospitalization
A change in environment for an older adult with any cognitive impairment can be a trigger for delirium. In intensive care units, increased sensory stimulation, such as bright lights and alarms, can cause a chaotic environment and confusion.
2. Infection/illness
Urinary tract infection (bladder infection), pneumonia, congestive heart failure, or a cardiac event are common ailments associated with delirium. Recent research suggests that delirium may be an initial sign of Covid-19 in people with dementia.
3. Dehydration
Older adults often do not drink enough fluids throughout the day. This can cause electrolyte imbalances, urinary tract infections, and constipation.
4. Constipation
As people age, their digestive system slows, and bowel function is reduced. Abdominal distention, nausea, and vomiting can all contribute to symptoms of delirium.
5. Medication
Overdoses, withdrawals, and side effects of drugs (or alcohol) can also contribute to the cause of delirium.
6. Metabolic imbalances
Fluid and electrolyte imbalances, hypoxia, and hypoglycemia can cause delirium. Metabolic causes include chronic conditions such as kidney, liver, or lung disease.
7. Pain
Poorly controlled pain in a person with generalized chronic or acute pain can contribute to symptoms of delirium.
8. Malnutrition
As we age, we may not have an adequate nutritional intake, which could cause electrolyte and glucose imbalance leading to delirium.
9. Medical procedures
Undergoing a medical procedure that requires sedation or anesthetic can lead to delirium in the post-procedure phase.
10. Sleep deprivation
Lack of sleep is a significant risk factor for disorientation and delirium.
Lifestyle tips for prevention
While some cases may not be preventable, modifying general lifestyle practices can reduce the chance of developing conditions that lead to delirium. Don't hesitate to contact your medical practitioner if you have concerns about your loved one's general health and well-being.
Maximize hydration: adequate hydration is essential to prevent urinary tract infections and constipation. Unfortunately, most older adults do not drink enough hydrating fluid throughout the day. Limit coffee, tea, or alcohol intake that can dehydrate and increase water consumption. If drinking enough water is difficult, try flavoring with products such as Mio. In addition, use or offer fluid-rich foods such as Jell-O, pudding, yogurt, or watermelon.
Maximize nutrition: Older adults often have a reduced appetite, so adequate nutritional intake can be challenging. Healthy snack foods such as fruit or granola bars and nutritional supplement drinks such as Ensure or Boost may enhance the diet. Promoting mealtimes in a more social atmosphere with other people may also increase consumption.
Maximize the mind: Promoting community with family and friends stimulates interactive conversation. In addition, activities such as reading, word puzzles, listening to music, or learning a new skill will expand cognition and exercise the mind.
Maximize the body: Regular daily movement or physical activity has reduced delirium incidents postoperatively in older adults. Take a walk outside or participate in an indoor community walking program. Chair exercise programs such as Sit and Be Fit are freely accessible on PBS stations or subscription-cost streaming systems if mobility is challenging.
Maximize sleep: Promoting a peaceful and restful environment to increase quality sleep can help prevent sleep deprivation that can lead to delirium. Avoid caffeine and alcohol, especially in the evening. In acute hospital settings, this may present a challenge. When possible, darken the room at night and keep interruptions to a minimum.
Maximize the senses: When prescribed, wearing glasses and hearing aids prevent sensory deprivation that can contribute to delirium, so if your loved one is in the hospital, make sure they have their aids. In addition, ensure regular screening appointments for vision and hearing. Finally, having a visual clock that displays the date and time will improve orientation.
John’s story continued
So, does John’s father have dementia? In this case, John’s father did have delirium caused by dehydration.
Once in the hospital, following treatment with intravenous fluids and physiotherapy, he was discharged home after a week. A month later, he was back driving his car and living independently.
Could there be some lingering cognitive deficits with John's father? That is possible because even when delirium occurs in a cognitively healthy person, there is an increased risk of dementia. Therefore, monitoring cognition and functional status are vital to recognize any lasting consequences of delirium.
Delirium presents as confusion with a sudden onset affecting a person's attention. In contrast, the confusion in dementia progresses over time, mainly affecting memory and function. As a result, people with dementia are at a higher risk of developing delirium. Still, the risk factors and causes of delirium are, for the most part, preventable. However, delirium is a medical emergency. You must contact your medical practitioner if you suspect your loved one has delirium. Early recognition and treatment of the cause are critical to the best possible health outcomes.
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