Delirium- Normal for Older Adults???

Every week I receive at least one phone call from a panicked family member concerning a parent with sudden-onset delirium. A typical scenario goes like this: "Mama is talking crazy. She saw a man with a baseball bat in her room and monkeys climbing all over the walls. She was okay yesterday but now she is out of her mind."

The caller often tells me that a family doctor or clinician said it is "probably Alzheimer's Disease." While the caller is upset and concerned, the medical staff remains ambivalent. However, delirium should be treated as a medical emergency, as it is associated with increased morbidity and mortality. Early diagnosis is key!

Delirium is misdiagnosed or under diagnosed in clinical settings 70% - 80% of the time. Medical staff often assume it is dementia or Alzheimer's Disease, depression, mania, schizophrenia, or just "normal" aging [and that may explain the apathy identified by the family member].


After asking a few questions, I am usually told that the older adult has been recently hospitalized, has undergone surgery with general anaesthetic, is taking a new medication, has relocated from home to longterm care, is dehydrated, or has a urinary tract infection. For older adults, those six are common triggers for delirium. Frail older adults with many chronic conditions are especially vulnerable to delirium.

Delirium is Latin for "off the track" and is also known as toxic psychosis and acute confusional state. Delirium is a temporary or transient reversible condition lasting from several hours to twelve days. It is characterized by the following:

• Disoriented





• Hallucinations





• Acute confusional state





• Visions and sounds

Some drugs that are common triggers for delirium include psychotropic drugs, antidepressents, anticholinergics, anticonvulsants, antiparkinsonian drugs, and H2 blockers.

In order to accurately diagnosis delirium, it is necessary to get a medical history, physical exam, lab work, and administration of the Confusion Assessment Method [CAM]. The CAM is administered by a qualified diagnostician and must have the first three criteria plus a fourth or fifth for an accurate diagnosis:

1. Acute change in mental status
   



2. Symptoms that fluctuate over minutes or hours
   



3. Inattention
   



4. Altered level of consciousness




5. Disorganized thinking

In order to minimize the distress level for the older adult, communication strategies include going along with the delusions and agreeing with the visions. Instead of responding with, "There are NO monkeys crawling around the walls!" say, "How many monkeys? What did they look like? Monkeys are so cute." Talking positively with the older adult about the visions and sounds minimizes distress for both patient and family member. Remember, don't panic if it happens: It is most likely a temporary condition.

Afterwards, the older adult may develop anxiety when recalling the delusional state. If that happens, reassure him/her that it is "normal" considering their recent events and no, it is not AD and he/she is not "crazy."


Sources:

Alagiakrishnan, K. (June 29, 2011). http://emedicine.medscape.com/article/288890-overview


American Psychiatric Association. (2005). Diagnostic and Statistical Manual of Mental Disorders [DSM-IV-TR]. (4th ed.). Washington, DC: American Psychiatric Association.


Beers, M.H., & Berkow, R. (Eds.). (2000). The Merck Manual of Geriatrics (3rd ed.). Whitehouse Station, NJ: Merck Research Labortatories.

Ouldred, E.E., & Bryant, C.C. (2011). Delirium: prevention, clinical features and management. Nursing Standard, 25(28), 47-56. Retrieved from EBSCOhost.

Salawu, F., Danburam, A., & Ogualili, P. (209). Delirium: Issues in diagnosis and management. Annals of African Medicine, 8(3), 139-139. doi: 10.4103/1596-3519.57235.