Delirium and Dementia
Duke Geriatric Education Center (GEC)
January 21, 2014
Duke GEC
www.geriatriceducation.duke.edu
Objectives
• Recognize that patients with dementia are at
high risk of developing delirium.
• Differentiate dementia and delirium in the
acutely ill older person
• Discuss strategies for preventing and
managing delirium in older persons.
Duke GEC
www.geriatriceducation.duke.edu
Delirium: Definition
• Acute disorder of attention and global
cognitive function
• Synonyms: organic brain syndrome, acute
confusional state
• Identifiable cause(s)
• Not dementia
Duke GEC
www.geriatriceducation.duke.edu
A BIG Problem
• Hospitalized patients over 65:
– 10-40% Prevalence
– 25-60% Incidence
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ICU: 70-87%
ER: 10-30%
Post-operative: 15-53%
Post-acute care: 60%
End-of-life: 83%
Duke GEC
www.geriatriceducation.duke.edu
Levkoff 1992; Naughton, 2005; Siddiqi 2006;
Deiner 2009.
Costs of Delirium
• In-hospital complications1,3
– UTI, falls, incontinence, LOS
– Death
• Persistent delirium– Discharge and 6 mos.2 1/3
• Long term mortality (22.7mo)4
HR=1.95
• Institutionalization (14.6 mo)4
OR=2.41
– Long term loss of function
• Incident dementia (4.1 yrs)4
• Excess of $2500 per hospitalization
Duke GEC
www.geriatriceducation.duke.edu
OR=12.52
1-O’Keeffe 1997; 2-McCusker 2003;
3-Siddiqi 2006; 4-Witlox 2010
Clinical Features of Delirium
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Acute or subacute onset
Fluctuating intensity of symptoms
Inattention – aka “human hard drive crash”
Disorganized thinking
Altered level of consciousness
– Hypoactive v. Hyperactive
• Sleep disturbance
• Emotional and behavioral problems
Duke GEC
www.geriatriceducation.duke.edu
Common Risk Factors for Delirium
Predisposing
• Advanced age
• Preexisting dementia
• History of stroke
• Parkinson disease
• Multiple comorbid conditions
• Impaired vision
• Impaired hearing
• Functional impairment
• Male sex
• History of alcohol abuse
Duke GEC
www.geriatriceducation.duke.edu
Precipitating
• New acute medical problem
• Exacerbation of chronic medical problem
• Surgery/anesthesia
• New psychoactive medication
• Acute stroke
• Pain
• Environmental change
• Urine retention/fecal impaction
• Electrolyte disturbances
• Dehydration
• Sepsis
Marcantonio, 2011.
Why Delirium Prevention and Treatment
Matters in Persons with Dementia
• Increased risk of delayed recognition and treatment
in persons with dementia
• 2 times Increased risk in rate of cognitive decline
for persons with dementia who develop delirium
• Increased risks of hospital complications and
delayed discharge, especially if left alone
Duke GEC
www.geriatriceducation.duke.edu
What Dementia Families Tell Us
• I thought it was just her dementia progressing, but
she was dehydrated and really sick.
• The Emergency Room was like an exhausting time
capsule – when he finally got a room, we thought it
was safe to go home and sleep.
• Why do we have to pay a sitter, given all that hospital
charges?
• The hospital staff either asked him impossible
questions he couldn’t hear anyway or talked about
him like he wasn’t there.
Duke GEC
www.geriatriceducation.duke.edu
Prevention of Delirium in Hospitalized
Patients with Dementia
• Constant presence of familiar transitional person
• Reassuring communication: Identity props,
reminders, something to do, sensory aids
• Eliminate wandering triggers – suitcase, coat, EXIT
• Adjust noise, temperature, view, TV risks
• Limit tethering, hide or use decoy
• Label and unclutter hospital room
• Increase mobility
• Nutrition and hydration
Duke GEC
www.geriatriceducation.duke.edu
Resources for Families
• Try this: Communication Difficulties: Assessment and Interventions
in Hospitalized Older Adults with Dementia (2013) 2pp.
www.Consultgerirn.org/uploads/File/trythis/try_this_d7.pdf
• Try this: Assessing and Managing Delirium in Older Adults with
Dementia (2013) 2pp.
www.Consultgerirn.org/uploads/File/trythis/try_this_d8.pdf
• Hospitalization Happens (2009)
www.nia.nih.gov/sites/default/files/hospitalization_happens.pdf
• REASSURE for DELIRIUM (Poer, 2011)
• Delirium: Unique to Older Adults (2012) www.Healthinaging.org
• Next Step in Care Family Caregiver Guide (2012): Emergency
Room (ER) Visits: A Family Caregiver’s Guide from the United
Hospital Fund. www.nextstepincare.org
Duke GEC
www.geriatriceducation.duke.edu