Delirium in Elderly Patients

We are pleased to announce the publication in March 2014 of a review of Delirium in elderly patients by Dr. Sharon Inouye, the main researcher and disseminator of this geriatric syndrome*. At present, health care safety policies are a priority element in all health care systems, and the confusing picture is a frequent, under-detected syndrome that greatly increases hospital costs and especially represents a very relevant risk factor for dependency and mortality in elderly patients. Delirium or acute confusional state, implies an alteration in the level of consciousness that affects attention, fluctuating throughout the day and which is usually produced by an illness or a side effect of medication. The frequent atypical presentation of diseases in the elderly makes this form of presentation frequent.

In the community it can affect 2% of the general population, with 14% of the population over 85 years of age. At a hospital level, it affects 30% of the elderly, depending on the care services, reaching figures of 70% in intensive care. See table.

The appearance of delirium supposes an independent risk factor of mortality at 6 and 12 months, having a great impact on the functional capacity, so a third of the autonomous elderly people with delirium after 2 years present a dependency. It is also a marker of cerebral vulnerability, reflecting a decrease in cerebral reserve and dementia.

In the community it is important that health care teams have a good knowledge of the cognitive and functional reality of elderly people, in order to detect early any relevant modification in their basal state, especially after therapeutic modifications. At hospital level, the systematic use of cognitive assessment tools or the use of the CAM (Confusion Assessment Method) scale in patients at risk is fundamental. It is important to carry out a double care strategy, on the one hand to carry out an assessment of the predisposing and precipitating factors to evaluate the cause of the problem and a global intervention to minimise the impact of hospitalisation on the life of the elderly and in the case of behavioural disorders that interfere with care or safety to treat them appropriately with neuroleptics at the appropriate doses and for the appropriate duration.

Multi-component interventions to prevent delirium are a good opportunity to adapt the care system to the characteristics and needs of the elderly person, as well as those measures of psychostimulation using clocks, calendars to guide the patient; adequate sleep management with adequate daylight, eliminating noise, excessive temperatures and comfort measures such as giving a glass of warm milk, relaxing music, avoiding vital signs checks or untimely nappy changes; prioritise early mobilisation, avoiding physical restrictions that triple the risk of delirium; ensure that they have dental prostheses, glasses, hearing aids and that they function correctly; early detection of signs of dehydration and a thorough and systematic control of the medication they are actually taking (especially psychopharmaceuticals and those with anticholinergic potential). Adequate pain control, as well as the possible presence or increase of constipation, and early removal of bladder or vascular catheters, should be a priority for detection and care. It can also be an opportunity to inform and educate the main carers, who in the moments of accompaniment can structure certain reorientation and prevention activities, to become involved in the multidisciplinary team itself and to know the global care objectives, as well as the inherent risks.

These multi-component strategies in a systematic review** are observed to reduce the incidence and severity of delirium, especially after hip fracture, without having a great impact on mortality or institutionalisation. It is also noteworthy that they greatly reduce hospital stay, with the duration in some studies being around 100 days, so that after solving the precipitating cause the brain's capacity to adapt is prolonged.

To all the people who attend to elderly patients, this updating of knowledge and possible prevention activities are of great interest and should raise the awareness of all the care resources in order to provide comprehensive and safe care.

* Inouye S, Westendorp R, Saczynski J. Delirium in elderly people Lancet 2014;383:911-921.

** Siddiqi N, Holt R, Britton AM, Holmes J. Interventions for preventing delirium in hospitalised patients. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005563. DOI: 10.1002/14651858.CD005563.pub2.