• Discuss common screening methods to identify delirium
• Identify common causes of delirium
• Understand common treatments for delirium
• Realize the sequela of delirium in the elderly

Angela R. Curtis, PhD
Managing Editor
Assistant Professor, Geriatric Education Manager
Division of Gerontology, Geriatrics and Palliative Care

Donna M. Bearden, MD, MPH
Assistant Professor, Division of Gerontology, Geriatrics and Palliative Care

University of Alabama at Birmingham
Birmingham, Alabama

Dr. Bearden has no commercial affiliations to disclose.

Because of the nature of preliminary studies, some products mentioned are unlabeled and investigational. Dosages, indications, and methods of use of drugs mentioned in this publication may reflect the experience of the authors, clinical literature, or other resources. Therefore, please see the full prescribing information before using any licensed product mentioned.

The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The University of Alabama School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The boards of nursing in many states, including Alabama, recognize Category 1 continuing medical education courses as acceptable activities for the renewal of license to practice nursing.

Delirium is an area of growing interest and concern among hospitals and healthcare providers. Increased age is associated with an increased risk for delirium, and it is estimated that 10-30% of elderly patients presenting to the emergency department are delirious. Furthermore, delirium occurs in 15 to 30% of patients after surgery, [1] and in the intensive care unit (ICU) the rates can be as high as 60 to 80%. [2] Not surprisingly, it has been shown that delirium can increase length of stay of hospitalization, as well as significantly increase cost of care. [3,4]

Given the above, one can understand the importance of developing methods to identify risk factors for delirium. Additionally, methods to identify delirious patients in the hospital, as well as effective prevention and treatment strategies gain mounting importance. In fact, the Assessing Care of Vulnerable Elders Project (ACOVE) considers delirium one of the top three conditions where quality of care needs to be improved. [1] CMS has also considered identifying delirium as a non-reimbursable hospital occurrence, meaning hospitals and health care providers stand to lose large amounts of money if the tide of delirium is not reversed. [1]

A CASE:

Mrs. O is an 88-year-old African-American female with a long history of hypertension, hypothyroidism, and osteoarthritis. She was transported to a tertiary care center by paramedics after sustaining a syncopal episode at home, while getting up one night to void. In the emergency department, she was found to have sustained a small non-ST elevation myocardial infarction. She was admitted to Cardiac Care Unit (CCU) and treated medically, given her advanced age and patient and family preferences. On admission, she denied any recent illnesses, infections, or medication adjustments. She lived with her daughter, who indicated that that the patient had no history of memory problems or confusion prior to this admission. In fact, she indicated that her mother read the newspaper daily, and played the piano on a regular basis. Unfortunately, two days after admission, the patient became uncooperative with her care. She continually pulled at IVs and other devices, and talked to people who weren’t in the room. During the day she would sleep for long periods, and then have episodes of intermittent agitation. Prior to admission, the patient’s medications at home were: levothyroxine 0.075 mg daily, hydrochlorothiazide 25 mg daily, and propoxyphene with acetaminophen (Darvocet N-100) three times daily for osteoarthritic knee pain. A geriatric medicine consult was obtained to assist with the evaluation and treatment of her “altered mental status.”

Her medications at the time of the consult were: risperidol 0.5 mg by mouth twice a day, haldoperidol 1 mg IV every 4 hours, as needed, metoprolol 12.5 mg by mouth every 12 hours, diphenhydramine 50 mg by mouth nightly, as needed, aspirin 325 mg by mouth daily, ranitidine 150 mg by mouth twice a day, clopidgrel 75 mg by mouth daily, and atorvastatin 80 mg nightly.

On examination, Mrs. O could intermittently answer simple questions, but at other times would abruptly change subjects when asked questions. She clearly had visual hallucinations during the examination as well, picking at things in the air that weren’t there. Her laboratory evaluation showed cardiac profiles consistent with a myocardial infarction, but was otherwise normal, including her TSH and electrolytes. After evaluating the patient, the clinician needs to determine if she’s delirious or not.