March 11 is World Delirium Awareness day—a problem you may have heard of, but perhaps do not appreciate its name or significance! We offer this update as we strive to be an age-friendly health system. Ochsner is committed to the four M’s of care for the older adult: Mentation, Mobility, Medications and What Matters Most.
Delirium is a brain disorder that comes on suddenly and can show up as confusion and disorientation or as being withdrawn and slow. It is differentiated from dementia, which is defined as memory impairment that interferes with day-to-day function with changes occurring over months or years, and psychosis, which is a psychiatric disorder where orientation, concentration and attention are preserved, but hallucinations and delusions are common. People with delirium can be agitated and combative, such as picking at their IV or sheets or trying to get out of bed, or barely responding to normal interactions. These behaviors can become worse in the late afternoon and early evening, so some refer to it as “sundowning.” Families are more aware of the patient’s normal behavior, so it is important to let the health care team know when something is different.
People at risk for delirium include those with advanced age or illness, such as patients with cancer, heart, lung or kidney disease and frailty, coexisting brain disorders, such as dementia, Parkinson’s disease and stroke, sleep deprivation, under-treated pain or sudden withdrawal from pain or sleep medications or alcohol and people who are immobile or have fractures. Vision and hearing loss may also be a risk factor, but they are often the simplest risk factors to fix as glasses and hearing aids are often a solution!
Delirium is very common, affecting about 30% of older adults in the hospital and more than 50% after surgery. It should be recognized, evaluated and treated because it can last days to months and worsens the short-term and long-term prognosis of a patient.
We should prevent delirium if possible by limiting the time away from home, bringing objects of comfort from home, such as photos or blankets, reassuring the person that they are going to be ok and reminding them gently where they are and why— even if it takes having the conversation every few minutes.
We should also avoid medications that are known to cause or worsen delirium, evaluate new or worsening illnesses, prevent harm to the patient and others and provide supportive care. Supportive care includes making sure the patient gets enough to eat and drink, all their bodily functions are working, such as the ability to empty their bladder and bowels, and avoiding the use of restraints. We should maintain normal sleep routines and have a familiar face in the room whenever possible to provide a soothing voice or touch which can improve the situation and avoid under and over stimulation. The patient should get out of bed if possible and eat in an upright position as if they were home.
Behaviors that risk harm to the patient and family or staff are also a concern. In the past, treatment has included medication and restraints. Current literature advocates those treatments only if the patient is a severe risk of harm and no other behavior modifications have been effective. See Health in Aging for this and more geriatric topics.