Delirium (Confusion)

What is Delirium (Confusion)?

Delirium is a medical condition that most often affects older people. It changes a person’s attention, awareness, and thinking. This means they may struggle to concentrate, maintain focus, or shift their attention. It can develop suddenly and can change throughout the day. Symptoms can differ from person to person, but they often involve changes in behaviour, like being overactive or underactive, and changes in sleep patterns.

Delirium is always linked to another medical condition and can’t be better explained by another ongoing or pre-existing brain disorder. There are many causes of delirium. It can be due to the direct effects of substance misuse or withdrawal, side effects from medication, infection, surgery, metabolic disorders, pain, or even simple things like constipation or having trouble urinating. It’s difficult to diagnose because its symptoms can be subtle, especially in cases where the person becomes less active. Delirium is serious, often avoidable, and can lead to higher healthcare costs as well as an increased risk of illness and death.

The focus should be on preventing and detecting delirium early, and treating the underlying cause. This piece looks at how to assess and manage delirium, and how healthcare professionals can work together effectively to deliver coordinated care and improve patient outcomes.

What Causes Delirium (Confusion)?

Delirium is a condition that shows the brain is under stress. It’s usually seen in people who are already vulnerable due to other health issues. However, it isn’t fully known why it happens, and there might not be just one reason. There are many different possibilities or theories, and it’s likely that one or more of these are involved in any occurrence of delirium. It’s generally believed that it’s the result of a complex process involving the interaction of pre-existing vulnerabilities in a person and exposure to harmful events or factors.

When it comes to delirium, there are two types of contributing factors: predisposing and precipitating. Common predisposing factors include being over 70 years old, having unrecognized dementia, functional disabilities, being male, poor vision and hearing, and mild cognitive impairment. Drinking alcohol excessively and having abnormal lab results can also increase the risk.

On the other hand, the precipitating factors can change a lot, but medication side effects make up about 39% of delirium cases. Medications, especially those affecting the mind like psychoactive medicines or ones that block the nervous system (anticholinergic drugs), can trigger delirium. The American Geriatric Society put together a list in 2019 called the “Updated AGS Beers Criteria,” which includes medications that might harm older adults, including those that could cause delirium. ACBcalc.com is a useful site that calculates the overall nervous system-blocking impact of a patient’s medications and suggests alternatives that might have a lesser effect.

Other events that could bring about delirium include surgery, anesthesia, low oxygen levels, untreated pain, infections, and sudden illness or flare-ups of long-term conditions. People who are very vulnerable, like those with severe dementia, might experience delirium from minor disruptions such as constipation, dehydration, lack of sleep, difficulty urinating, or small medical procedures.

Delirium can come and go, but it can persist in some cases, particularly in those who have predisposing factors. Findings reveal that it stays until hospital discharge in 45% of cases and continues a month after in 33% of cases.

Risk Factors and Frequency for Delirium (Confusion)

Delirium is more common in older people and is often seen as a complication following surgery. For major scheduled surgeries, up to 10 to 20% of elderly patients can experience delirium. This percentage can rise up to 50% for surgeries that carry greater risks. After surgery, delirium can increase the chances of dying within 30 days by 7 to 10% and extend the hospital stay by 2 to 3 days.

Delirium not only affects the elderly but is a concern for the general population as well. It contributes to more usage of healthcare services, leading to increased complications and poorer patient outcomes. The total annual cost to healthcare due to delirium is estimated at $164 billion. In those who come to the emergency room with delirium, the risk of dying within six months rises by 70%. Moreover, delirium in the intensive care unit (ICU) can double to quadruple the risk of death.

• Delirium is more prevalent in older adults.
• It often occurs after surgery, affecting 10 to 20% of patients after major elective surgery and up to 50% after high-risk procedures.
• Postoperative delirium can increase the risk of dying within 30 days by 7 to 10% and prolongs hospital stay by 2 to 3 days.
• Delirium causes increased usage of health care services in the general population, leading to higher complications and poor outcomes.
• The health care costs due to delirium are estimated at $164 billion annually.
• If a person comes to the emergency department with delirium, the risk of death within six months is increased by 70%.
• Delirium in the ICU can multiply the overall risk of death by 2 to 4 times.

Signs and Symptoms of Delirium (Confusion)

Delirium, often indicating a serious health concern, requires a complete evaluation for appropriate treatment. This usually involves comprehensive history taking, physical examination, laboratory tests, and possibly, imaging. It’s important to remember that this condition can be triggered by various factors or a combination of them.

Delirium usually presents in three main forms:

• Hyperactive Delirium: Patients might manifest increased agitation, hallucinations, delusions and sometimes, uncooperative behavior.
• Hypoactive Delirium: Characterized by excessive sleepiness and decreased alertness, this form of delirium often goes unnoticed, mistaken for fatigue or depression. It is associated with higher risks of health complications and mortality.
• Mixed Presentation: Patients exhibit symptoms that oscillate between hyperactive and hypoactive delirium.

The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) defines delirium using the following criteria:

• Presence of attention and awareness disturbance that develops suddenly and varies in severity.
• At least one additional cognitive disturbance.
• The disturbances cannot be exclusively attributed to preexisting dementia.
• The disturbances do not happen in the context of a significantly reduced awareness level or coma.
• Proof of an underlying biological cause or causes.

Delirium can also alter sleep patterns, perceptual disturbances, delusions, unsafe behavior, and emotional instability.

Detecting delirium is crucial in its evaluation and treatment. It often develops within hours to days. It’s easier to spot hyperactive delirium as patients may cause disturbances, while hypoactive delirium is often overlooked as patients are less disruptive. Caregivers may hint at the presence of hypoactive delirium with comments related to the patient’s changed behavior or routine.

The Confusion Assessment Method (CAM) is a commonly used tool to detect delirium. It’s validated for 94% to 100% sensitivity and 90% to 95% specificity in diagnosing delirium. The criteria include:

• Acute change in mental state with fluctuations in disease severity.
• Inattention (struggle to maintain attention and follow conversations).
• Disorganized thinking (issues with memory, orientation, or language).
• Altered consciousness level (increased vigilance, sleepiness, or stupor).

The tool can be adapted for specific populations, like the CAM-ICU for ventilated patients, and for those in emergency departments or nursing homes.

When evaluating a patient with delirium, it’s important to consult with caregivers or others who know the patient well. Many patients with delirium also have underlying dementia, so knowing the patient’s baseline functionality helps to understand the acute changes. Some key questions to ask include changes in medicines, onset of new symptoms like cough or fever, sleep deprivation, environment changes, and recent falls.

Additionally, it’s crucial to review all past and current medications to avoid any drugs that can trigger and prolong delirium, including psychoactive or anticholinergic medications.

Testing for Delirium (Confusion)

A complete physical check-up from head to toe is typically carried out. This would look closely at your heart, lungs, nervous system, mental state, stomach, muscles, and skin. Also, your vital signs such as heart rate, temperature, blood pressure and breathing rate will be checked. The specific exams done would depend on the findings from the physical exam and your past medical history.

Patients suffering from delirium can find medical assessments stressful, which may intensify their symptoms. Hence, doctors often start by focusing on the most likely diagnoses based on the patient’s condition. First, a full blood count, oxygen and carbon dioxide levels in the blood (if necessary), complete metabolic panel and urinalysis are commonly recommended. Other tests such as a chest X-ray, electrocardiogram (an electrical heart activity recording), and bladder scan are also usually recommended. If required, additional tests like a spinal tap (lumbar puncture), an electroencephalogram (brain activity recording), and toxicology studies may be carried out. Blood cultures might be needed if there’s suspicion of an unclear source of sepsis (a severe infection), and brain imaging might be used in certain cases. The doctor may also check for source of pain that may have not been treated, like constipation.

The identification of delirium depends largely on clinical examination. There have been attempts to identify specific biological markers to assist in diagnosing and tracking delirium, such as inflammation markers, cortisol, interleukins, and C-reactive protein. However, none of these markers have been validated for consistent use in a clinical setting.

Treatment Options for Delirium (Confusion)

The primary approach to treating delirium is through non-drug measures, as there are no formally approved medications for preventing or treating this condition. The most effective measure is to prevent delirium in the first place. It’s crucial to identify those at risk and take steps to avoid onset. Non-changeable risk factors include having an existing brain disorder like dementia or getting older. However, we can control other factors like medications, infections, environmental elements, and reduced sensory input.

The American Geriatrics Society supports a program called HELP (Hospital Elder Life Program). It has proven to help reduce the occurrence of delirium in older patients. The program includes numerous components. Measures encompass minimizing environmental disturbances and prioritizing good sleep. Daytime guidelines recommend using aids like eyeglasses or hearing aids to optimize senses, tools to improve orientation like clocks, calendars, and promoting good practices like rising early, and drinking plenty of fluids. The program favors mobility and reducing limitations like catheters or IV lines. They also encourage therapeutic activities like music therapy where feasible. These strategies have proven to be cost-effective and remain the primary treatment for delirium. The HELP program has also been showcased to reduce the rate of falls by 42% and reduce hospital costs per patient from $1600 to $3800, and over $16,000 per person-year of long-term care costs in the year following a delirium episode.

While the main treatments for delirium are prevention and non-drug interventions, there are situations where drug therapies may be necessary. Patients experiencing delirium due to withdrawal from substances may need appropriate drug treatments, like using benzodiazepines to manage alcohol withdrawal. Patients at the end of life might also need drug therapies to ease their pain and suffering. It’s also crucial to treat the root cause of delirium, such as prescribing antibiotics for infections. Patients with a type of delirium that makes them a threat to themselves or others may need drug treatment. In these cases, antipsychotics are the recommended first-line treatment, with commonly used options including haloperidol, quetiapine, and risperidone.

The drug of choice depends on reducing side effects and the patient’s existing health conditions. For example, patients with Parkinson’s disease are best treated with quetiapine, and haloperidol is avoided. The dose of antipsychotic medications should be adjusted daily and monitored until no longer needed. It’s also essential to regularly check a patient’s heart activity with an EKG as antipsychotics can cause a prolonged QTc interval.

Various medications have been evaluated for preventing and treating delirium, yet lots of studies have seen no clear contribution to reducing its incidence. Melatonin, commonly used for regulating sleep patterns and its anti-inflammatory properties, sometimes helps decrease the incidence of delirium, yet other studies show it has no significant effect. Cholinesterase inhibitors have been evaluated as well but there’s minimal evidence to support their efficacy, and their potential risks may outweigh any benefits of their use.

What else can Delirium (Confusion) be?

• Dementia
• Psychosis
• Depression
• Paranoia
• Coma
• Catatonia (a state of unresponsiveness)
• Central nervous system cancer
• Nonconvulsive status epilepticus (a type of severe seizure)

What to expect with Delirium (Confusion)

The overall outlook for patients with delirium is uncertain.

Possible Complications When Diagnosed with Delirium (Confusion)

Several potential complications can occur as a result from various conditions or diseases. Here are some examples:

• Aspiration pneumonia: This is an infection that inflames the air sacs in one or both lungs which can result in filling up with fluid or pus
• Pressure ulcers: These are injuries that develop when constant pressure or friction on one area of the body damages the skin.
• Weakness, decreased mobility, and decreased function: This can make it challenging for an individual to carry out their daily tasks and activities.
• Falls and combative behaviour leading to injuries and fractures: A medical condition or medications might increase the risk of falls or injuries.
• Malnutrition, fluid and electrolyte abnormalities: If the patient is not receiving the necessary nutrients and hydration they need, it can lead to malnutrition and electrolyte imbalance.
• Long-term cognitive impairment: Delirium can be more than just a temporary, reversible state of confusion. It has been shown that it can also result in persistent long-term mental impairment.
• Increased mortality: The risk of death can increase due to these complications and the underlying conditions or diseases which caused them.

Preventing Delirium (Confusion)

To minimize the risk of confusion or delirium, it is beneficial to maintain a regular sleep schedule and ensure that the patient begins moving around as soon as possible. If they use a hearing aid or glasses, make sure these are readily available to them. It’s important to manage any pain they might be experiencing appropriately, as well as keep them well-hydrated and well-fed.

Keep an eye on their bowel and bladder movements, endeavour to detect any signs of delirium early, and aim to create a calm and comfortable environment. Try to keep them away from stressful situations. Regular communication with the patient aids in their well-being. If any complications arise or if delirium sets in, be sure to refer them to a specialist as soon as possible.