Gideon Caplan, Director, Geriatric Medicine, Prince of Wales Hospital, Sydney
Summary is poorly understood. Susceptibility to this condition reflects a
balance between the severity of the insult and the frailty of the Delirium is an acute syndrome characterised central nervous system, so anyone can get delirium. It is not by altered levels of consciousness, attention unusual in patients in intensive care or young people using and cognitive function. It has many causes recreational drugs.
and frequently leads to, or occurs during, Risk factors for delirium include dementia, older age, multiple
hospitalisation. Delirium requires urgent medical comorbidities, psychoactive medication use, sleep deprivation, dehydration, immobility, pain, sensory impairment and assessment. Unfortunately, the diagnosis is often hospitalisation. Delirium is closely linked to dementia – each is a missed. It is best treated by multidisciplinary risk factor for the other – and it is now recognised that delirium intervention, addressing risk factors, treating can cause irreversible decline in cognitive and physical function, underlying causes and minimising harm. Part of as well as increased mortality and nursing home placement. its management may be pharmacological, firstly Frail older patients may present with delirium triggered by ceasing drugs which may precipitate delirium – many medical or surgical problems (see box), often more than
especially those with anticholinergic properties – one at a time, so delirium presents a diagnostic challenge. Because it may be the only presenting symptom of a rapidly and secondly, cautious use of antipsychotics for deteriorating patient, delirium is a medical emergency. hyperactive symptoms. Key words: aged, antipsychotic, dementia. Preventing or reducing delirium (Aust Prescr 2011;34:16–18) Multicomponent interventions have reduced aspects of delirium2 such as delirium incidence, severity and duration, Introduction though not all three simultaneously. The Hospital Elder
Delirium is an acute syndrome of altered level of consciousness, Life Program (HELP) (www.hospitalelderlifeprogram.org),
decreased attention and cognitive function, usually coming administered by volunteers and ward staff, addresses six of the on over hours or days. It occurs most often in older people, risk factors for delirium, namely cognitive impairment, sleep associated with acute medical or surgical illness. It is commonly deprivation, immobility, dehydration and visual and hearing seen during hospitalisation – it affects up to a quarter of older impairment. The program recommends the following: hospitalised people on admission to hospital and a half can n reorient and mobilise the patient develop delirium during the admission.1 Delirium may also n reduce sensory deprivation develop at home, and is common in post-acute care, residential n ensure the patient is hydrated aged care and palliative care settings. n implement a non-pharmacologic sleep regimen Symptoms n limit catheters and restraints. The symptoms of delirium usually fluctuate throughout the day and night, with disturbance of the sleep–wake cycle resulting in agitation at night and drowsiness during the day. Box The presentation varies, ranging from the floridly agitated, MISTE – a mnemonic for possible causes of delirium hyperalert, hyperactive patient to the drowsy, hypoalert M metabolic – hyponatraemia, hypoglycaemia, patient sleeping quietly in their bed. Many patients have a hypoxaemia mixture of symptoms including inattention, varying degrees of I infective – urinary tract infection, pneumonia consciousness, hallucinations and delusions. Hypoalertness in patients is often mistaken for dementia, resulting in delayed or S structural – subarachnoid haemorrhage, urinary retention missed opportunities for therapeutic intervention. T toxic – drugs (e.g. digoxin, lithium) or poisons
E environmental – being in hospital or the emergency
Risk factors department Despite being so common, the pathophysiology of delirium
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Intensive orthogeriatric services, involving daily geriatrician Pharmacological management review starting before surgery, reduce delirium in hip fracture Appropriate management of the underlying condition(s) and patients.3 An Australian study found that multidisciplinary the drugs that the patient is taking, remains the mainstay of geriatric rehabilitation in the home reduced the incidence delirium treatment. of delirium compared to when it was given in hospital.4 Haloperidol prophylaxis for hip surgery patients had no effect Stopping drugs that cause delirium on delirium incidence, but did reduce the severity and duration,5 The importance of reducing or ceasing drugs that exacerbate whereas risperidone after cardiac surgery was found to reduce delirium cannot be overemphasised. This highlights the incidence of delirium.6 the importance of a thorough medication review. While anticholinergics and psychoactive medications (including Diagnosis and initial management antiepileptic and pain medications) are important, other The crucial, and unfortunately, often missing step in delirium drugs such as NSAIDs and sotalol may also contribute to the management is diagnosis. Given the large and increasing problem (see box). Even drugs that are used to treat delirium, number of older patients in hospital, screening for delirium particularly if given in excess, can prolong or worsen delirium. should become part of routine observations, at least for high- It is also important to enquire about over-the-counter and risk patients. However, some training of staff is required. complementary medications, such as European mandrake or
It is very useful, when unsure if a patient's poor cognitive status scopolia which have marked anticholinergic properties, as these
is new or pre-existing, to ask their family or carer whether they may precipitate delirium.
are usually like this.
Drug therapy for delirium Once delirium is identified, initial management aims to detect Drug therapy is reserved for patients who are at risk of harming and treat underlying medical and surgical causes. The list of themselves or others, for example by pulling out essential possible causes is long, and the simple mnemonic MISTE medical devices or lines. Drug treatment for delirium is an serves as an aide-memoire to categorise potential causes understudied area, with only a limited number of small trials (see box). A comprehensive assessment including history, to guide management. There are very few data comparing examination and appropriate investigations is required when different drugs. The choice of drug is not guided by an delirium is detected, because many older patients have more understanding of the pathophysiology of delirium, which than one diagnosis contributing to their delirium. remains imprecise. After delirium has developed, addressing the six HELP risk factors is useful. Managing a patient with hyperactive delirium Antipsychotics can be a challenge on any ward. Restraints should be avoided, If drugs are needed, antipsychotics are generally accepted as as they aggravate delirium, as well as increase injuries and first-line, except in delirium tremens. However, phenothiazine falls. Where suitable, asking family to be present as much as antipsychotic drugs such as chlorpromazine, which have possible, even organising a roster of relatives, generally helps to prominent anticholinergic properties, should be avoided in older calm agitated patients. If this is not an option, ask an assistant- patients. Always remember the essential aphorism of geriatric in-nursing to sit with the patient. A delirium room or ward pharmacology: start low and go slow. Suggested initial doses where a calm, comfortable environment can be maintained is are haloperidol 0.5 mg, risperidone 0.5 mg or olanzapine 2.5 mg.
most beneficial for patients. Familiar objects or photographs Depending on the response additional doses can be given
from home also help. after 2–4 hours, otherwise daily. However for the more frequent dosing, the patient should be closely monitored for It is important to prevent complications so, for example, over-sedation. agitated patients who keep climbing out of bed may be nursed on low-low beds or mattresses placed on the floor. It is Efficacy preferable to allow an agitated patient to pace around a secure A number of small trials have shown that typical (particularly delirium ward than to sedate them as this can lead to hypostatic haloperidol) and atypical antipsychotics improve hyperactive pneumonia or pressure sores. symptoms, such as agitation, restlessness, thought and Designing appropriate and safe facilities to manage patients perceptual disturbance, and shorten the duration of delirium. with delirium should be a priority in building new hospitals. Hypoactive symptoms such as drowsiness and sedation As patients may become delirious on any ward in the hospital may be exacerbated. There is no clear evidence that atypical it is useful to have a support person, such as a clinical nurse antipsychotics are more effective than typical antipsychotics, but consultant, who can advise and train staff around the hospital. they appear to have fewer extrapyramidal adverse effects.
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Adverse effects References Extrapyramidal effects include akathisia (motor restlessness and 1. Inouye SK. Delirium in older persons. N Engl J Med muscular tension especially in the legs) and parkinsonism. These 2006;354:1157-65. 2. Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, may occur in over half of older patients on antipsychotics, with the Acampora D, Holford TR, et al. A multicomponent risk increasing with higher doses and longer duration of treatment. intervention to prevent delirium in hospitalized older Antipsychotics may prolong the QTc interval. Neuroleptic patients. N Engl J Med 1999;340:669-76. malignant syndrome, a rare but potentially fatal disorder, is also 3. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. more common with typical antipsychotics. It develops over 1–3 Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 2001;49:516-22. days, and symptoms include fever, extrapyramidal dysfunction 4. Caplan GA, Coconis J, Board N, Sayers A, Woods J. Does with tremor and marked rigidity, autonomic disturbance home treatment affect delirium? A randomised controlled including tachycardia and hypo- or hypertension, elevated trial of rehabilitation of elderly and care at home or usual creatine kinase and white cell count, and myoglobinuria. If treatment (The REACH-OUT trial). Age Ageing 2006;35:53-60. suspected, antipsychotics should be ceased immediately and 5. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, Vreewijk R, supportive measures instituted, including intravenous fluids. Egberts TC, Burger BJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a Other adverse effects of antipsychotic drugs that affect older randomized placebo-controlled study. J Am Geriatr Soc people during short-term treatment are sedation, orthostatic 2005;53:1658-66. hypotension, epileptic seizures, weight gain and disturbed 6. Prakanrattana U, Prapaitrakool S. Efficacy of risperidone glucose and lipid metabolism. Sedation may, at times, be a for prevention of postoperative delirium in cardiac surgery. desired effect but at other times it is an adverse effect, prolonging Anaesth Intensive Care 2007;35:714-9. the delirium and increasing the risk of falls and fractures. Further reading Evidence has emerged of an increased risk of stroke in older Clinical practice guidelines for the management of delirium in older patients with dementia taking atypical antipsychotics, however people. Melbourne: Victorian Government Department of Human the risk is thought to be similar with typical drugs. Services, Australian Health Ministers' Advisory Council; 2006. www.health.vic.gov.au/acute-agedcare [see also 'Quick reference Other drugs guide' and consumer brochures] [cited 2011 Jan 5] Benzodiazepines are the treatment of choice for delirium Bourne RS, Tahir TA, Borthwick M, Sampson EL. Drug treatment tremens and delirium associated with benzodiazepine of delirium: past, present and future. J Psychosom Res 2008;65:273-82. withdrawal. They can also be used in patients with neuroleptic Therapeutic Guidelines: Psychotropic. Version 6. Melbourne: malignant syndrome, Parkinson's disease or Lewy body Therapeutic Guidelines Limited; 2008. dementia. However, the atypical antipsychotics may be used with caution in the latter two conditions. Conflict of interest: none declared Although anticholinergic drugs can contribute to the development of delirium, and ceasing them often helps improve delirium, there is no randomised evidence that the cholinergic drugs used to treat dementia (donepezil, galantamine or rivastigmine) have a role in the treatment of delirium.
Conclusion Delirium is a common emergency, with high mortality rates, Self-test questions affecting older patients. Timely diagnosis, investigation, The following statements are either true or false multicomponent intervention and judicious use of medications (answers on page 31) to treat and protect the patient can improve the chances of 5. Dehydration is a risk factor for delirium in older people. a good outcome. It is imperative that any hospital caring for 6. Benzodiazepines are recommended for the treatment significant numbers of older patients maintains a coordinated, of delirium tremens. multifaceted response to delirium.
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