SCOA: Delirium (Acute Confusion)

Topic Overview

Delirium is common in older people.
Delirium has the following characteristics:

sudden onset and fluctuating course of confusion
inattention
disorganized thinking
altered level of consciousness

Delirium and dementia both present as confusion but they are different illnesses.
There are many causes of delirium.
Delirium is a medical emergency.

Introduction

Delirium is quite common in older adults, affecting nearly one-third of those admitted to hospital.
Sometimes delirium accompanies a physical illness like pneumonia or a stroke. Other times, it is the first warning of medical illness.
Regardless of its cause, delirium is a serious medical condition – early recognition and treatment is essential.
Delirium duration may range from a short episode to a few days (and even a few weeks or months), depending on the cause.

What You Should Know

Characteristics of Delirium

Delirium has the following features:

Acute onset and fluctuations – Confusion usually develops suddenly and progresses over the next few hours or days. The confusion fluctuates and there may be periods of agitation and restlessness.
Impaired attention – The person has difficulty concentrating on conversation and with familiar tasks. They get easily distracted and have difficulty following simple commands,
Disorganized thinking – They may not know what day it is, where they are, or even who they are. Thinking is confused. Speech may be rambling or jumbled. Unusual suspicions, paranoia, or hallucinations may occur.
Changes in level of consciousness:

In hyperactive delirium, the person is agitated, with mood swings, at times angry, belligerent, and aggressive towards caregivers. For example, after surgery, they may try to climb out of bed, yell at caregivers, or pull out catheters and IV lines.
In hypoactive delirium, there is extreme drowsiness, fatigue, and lethargy. These episodes may be misinterpreted as the person “just being ill and resting.”

Risk Factors

Individuals with the following characteristics are the most likely to have delirium:

advanced age
cognitive impairment or dementia (older people with dementia are especially susceptible to delirium)
history of previous episodes of delirium
multiple medical conditions
multiple medications
severe stress (from events like a move to a new environment, recent surgery or recent injury)
sensory deprivation; hearing and visual impairment

Dementia and Delirium

Dementia and delirium share some common features and it is important to tell them apart.Dementia is a chronic, slowly progressing loss of memory and function. On the other hand, delirium develops quickly. It is a warning of a serious underlying medical condition.

Differences Between Dementia and Delirium

	Dementia	Delirium
Onset	slow onset over months or years	sudden onset over hours or days
Course	progressive	fluctuating
Speech	normal	rambling
Attention	normal	inattentive, easily distracted
Memory	gradual and progressive memory loss	variable
Hallucinations	possible	Common especially visual
Level of consciousness	normal	impaired
General health	usual	signs of illness or drug side effects

Causes of Delirium

Many medical conditions and other problems can lead to delirium. Remember this helpful hint – the letters in the word "DELIRIUM" stand for the common reasons for this condition.

Drugs	many medications, recently started or stopped, changes in dosages, over-the-counter medications, herbals, alcohol
Electrolyte imbalance	especially from dehydration
Lack of drugs	stopping certain medications, alcohol withdrawal
Infection	such as urinary or respiratory tract infections; blood or wound infection after an injury or surgery
Reduced sensory input	such as poor or uncorrected vision and hearing
Intracranial	such as from a stroke
Urinary or fecal problems	such as inability to empty bladder or bowel
Myocardial (heart) and lungs	heart attack, pneumonia, or other condition causing lack of oxygen in the blood and the brain

Medical Attention Is Always Needed in Delirium

Early detection and treatment is essential because delirium is a sign of a serious underlying medical condition. In addition, older people with delirium are susceptible to injuries, falls, dehydration, pressure sores, and malnutrition.

Delirium is a medical emergency. Accompany the person with delirium to the emergency department, and be ready to provide information on:

past medical problems
current medication list
cognitive history
details of everyday functioning and thinking before the confusion