Updated August 27, 2021
what questions should I and my family be asking?
Why is my loved one confused? Do they have less attention, alertness, and odd behaviour or speech?
Did they miss a medication they were supposed to take?
Are they diabetic and their blood sugar low?
Did anything change recently?
Did they get a new medication, fever, or injury?
Did this happen before?
Are they dehydrated, constipated, or in pain?
Do they have their glasses or hearing aids on?
Have they ever been assessed for their mental health or thinking (cognition)?
What actions can i take for this agenda?
Keep track of ways to improve your senses such as using your glasses and hearing aids
Avoid injury by decreasing your risk of falling and using your gait aids if you have them. Refer to the “falling” agenda for more details
Make sure your family reorients you in hospital by telling you who you are, what the date is, and where you are
Make sure you sleep well during the night and stay awake and socially stimulated during the day
Keep track of your medications and that you’re taking them correctly. Refer to the “medications” agenda for more details
Avoid medications that can increase your sleepiness such as opioids, benzodiazepines, and sleeping pills
Decrease your risk of getting infections by knowing good urination hygiene to avoid bladder infections and getting the flu shot and other needed vaccines every year to avoid lung infections
Avoid constipation by drinking water and eating a lot of fiber
Always talk to your doctor about the benefits and risks of a procedure you potentially need to go through
Ask your family doctor to review your mental health and thinking (cognition) if needed
What are confusion and delirium?
Confusion is defined as a lack of understanding
It is the state of being bewildered or unclear in one's mind
Delirium is a quickly occurring state of confusion
As we age, our brains become more vulnerable
As such, any body stress can cause the brain to be confused
Delirium has many causes and is usually reversible
About 30% to 40% of older adults will develop delirium during their stay in hospital. That risk goes up as we age
How does delirium present?
It can be difficult to diagnose delirium from someone who does not know the person well. Usually, family members mention to healthcare providers that their loved one is confused
There are four key parts of delirium:
1) Decreased attention (the key symptom)
2) Quickly occurring (acute) and varying from normal to confusion back and forth (fluctuation)
3) Disorganized talking and thinking (not able to keep track of the conversation and saying random things)
4) Decreased wakefulness (lower level of consciousness)
delirium is a quickly occurring state of confusion. Its risk increases with age and in hospital
The most important part of delirium is lack of attention
It has many causes and is usually reversible by treating the cause
what causes delirium?
Many stressors and illnesses can cause delirium
Sometimes, it is a combination of these causes and not just one that leads to it. The most common causes are:
1) Medications:
Drugs can cause our brains to be more sedated and can lead to confusion. Even medications dosed correctly can sometimes cause confusion. As we age, we become more sensitive to drugs. Refer to our “medications” agenda for more details
Common medication classes that can cause delirium are benzodiazepines, anticholinergics, opioids, sleeping pills, antipsychotics, and many more. It is important to remember that these medications might be right for you and should not be started or stopped without talking to your doctor first
2) Infections:
Any infection can lead to delirium. The most common infections in older adults are bladder tract infections (UTI) and lung infections (pneumonia)
3) Body chemicals and metabolism:
There are many chemicals and bodily proteins that maintain a balance of our body functions. A change in that balance, chemical, or protein can lead to delirium. Examples of this is our thyroid, liver, and kidney function. Also, the level of oxygen our brain is getting, our blood salts (electrolytes) such as sodium, and blood sugar levels cause confusion if they’re too high or too low
4) Structure:
Injury to our brain’s structure can also lead to confusion. Strokes, seizures, and stressful surgeries can all do this
5) Other:
There are other abnormal body changes that can cause delirium. Examples are being low on fluids (dehydration), pain, sleep loss, and constipation
Even a change in one’s environment such as being in a hospital can cause confusion. Decreasing our senses can worsen this too such as poor vision and hearing
how is delirium diagnosed?
There is no specific blood test or imaging we do to diagnose delirium. It is a “clinical diagnosis” meaning we look at the symptoms and signs of the patient as described in how it presents
We still do blood tests and imaging to work up the causes for delirium to tease out what is causing the confusion
Sometimes it can be more than one cause
Many things can cause delirium such as medications, infections, chemical changes, and brain injury
dehydration, surgery, pain, poor sleep, and constipation are also other risk factors
what are the types of delirium?
There are two types:
1) Increased activity delirium (hyper-active):
The more common type where the patient is over-actively confused and not sleeping or resting much
2) Decreased activity delirium (hypo-active):
The less common type where the patient appears to always be sleeping, resting, and not engaging with others. This type is more difficult to notice and has a worse outcome
Why does the confusion sometimes get worse in evening and night times?
This is called “sundowning”
We do not know exactly why this happens. Some thoughts are that the brain and body are more exhausted
The brain becomes even more confused and sensitive to stress and the environment later in the day
How is this confusion (delirium) different than dementia?
Delirium is more of a quickly occurring type of confusion with loss of attention. It is usually reversible and has an underlying cause
Dementia however is a slow and gradual change in our brain causing our thinking (cognition) to decline
Dementia is a broad term that has many types. One type of dementia is Alzheimer’s dementia
This change in thinking can affect many parts of our brain, not just memory. Dementia is usually not reversible and lifelong
Refer to the “mind” agenda for more details
delirium is different than dementia
having dementia increases your risk for delirium. Getting delirium can make your dementia even worse
why is delirium a burden?
Becoming confused can lead to many problems. One of them is needing to be admitted to the hospital so that the healthcare team can look into what’s causing it and treat it
Delirium causes a lower quality of life and lengthens hospital stays
Having delirium increases the risk of having delirium again when the body is stressed
Delirium can cause a decrease in someone’s thinking (cognition) and possibly may not fully recover to how their thinking was before they became confused
Different people present and recover differently
How long does delirium last?
This differs from person to person
It depends on how robust or frail our brains are
It also depends if someone had thinking (cognition) problems before too
Usually, treating the underlying cause of delirium makes it go away
Delirium can take up to three months or more in some cases to resolve. Given that delirium and the brain is complicated, it is very difficult to estimate in each older adult how long it will last for
delirium can take up to three months or more to resolve
In some cases, the changes in thinking do not improve back to the level of thinking that was present before the confusion started
what is the treatment for delirium?
The key and most important treatment for delirium is treating the underlying cause. That is why it is very important to identify the source of the confusion
For example, if it is a medication that is suspected, it is stopped. If it is an infection, we provide antibiotics. If it is a change in our sodium or sugar levels we try to get those back to normal. If it is from a stroke, seizure, or injury we address that and so on
Another very important part of treating delirium is making sure the patient and their environment are the best they can be to be oriented and less confused
In fact, studies have found that this approach has shown great results much more important than other types of treatment
We can address issues with the patient and with the environment to help such as:
1) Changes to help decrease confusion by looking into the patient:
Improve their vision and hearing by bringing their glasses and hearing aids. Improve their awareness by making sure they sleep at night and wake up during the day. Provide a window in their room. Make sure they are in their own clothes and not a hospital gown. Make sure they are eating three meals a day
2) Changes to help decrease confusion by looking into their environment:
Make sure they are socially and mentally stimulated and engaged. Have family and friends visit them to reorient them. Provide a clock in the room. Provide a calendar with the date and where they are
Figuring out the cause is key in treating delirium. reorienting someone with delirium can help
are there medications that can help? What should we do if they get agitated?
There are drugs that can decrease agitation. However, they come with many side effects and usually have temporary benefits
In some cases, they can even cause more harm than benefit. These drugs are usually not used and only as a last resort if someone is very agitated and aggressive
Even then, studies have found that addressing the confusion with non-medication approaches is far better. These drugs can also cause distress and can even make the confusion last longer. The class of medication commonly used is “antipsychotics”
Physical restraints can be harmful. Unless someone with delirium is causing harm to themselves or others, they should be avoided or used as least as possible
Your doctor and healthcare team are best to answer and know if someone they are looking after needs these medications or not
we usually do not use medications and physical restraints to treat the confusion. This can cause harm and usually has little benefit
orientation and treating the cause are much more important methods
Is it true that having surgery can increase my risk of having delirium after?
Yes, surgery is stressful on the body and brain and may lead to delirium afterward. It is always a discussion with your doctor to know the risks and benefits of the procedure you will have
There are factors that can increase your risk for delirium such as being over the age of 70, high alcohol use, having dementia, or depression
What can we do to prevent or manage delirium in the hospital besides treating the cause?
Mobilize early and regularly
Avoid urinary catheters or remove them as soon as no longer needed
Skincare and avoid pressure wounds
Avoid physical restraints as much as possible
Eat and drink as soon as you can
Sleep at night and stay active during the day
Wear your glasses and hearing aids
Have a clock, calendar, and window in your room
surgery can increase your risk of getting delirium afterward. talk to your doctor about those risks
What resources can help with this Agenda?
patientsafetyinstitute.ca
Integrated strategy for improving patient safety in the Canadian healthcare system which named establishing the Canadian Patient Safety Institute as its number one recommendation. Health Canada supported the creation and the funding of the Canadian Patient Safety Institute
ccsmh.ca
Canadian Coalition For Senior’s Mental Health. Their mission is to promote the mental health of seniors by connecting people, ideas and resources
cmaj.ca
The Canadian Medical Association Journal (CMAJ) is a peer-reviewed general medical journal that publishes original clinical research, commentaries, analyses, and reviews of clinical topics, health news, clinical practice updates and thought-provoking editorials
References
Robert L Kane et al. Essentials of Clinical Geriatrics 8th edition (2018)
Jeffrey B. Halter et al. Hazzard's Geriatric Medicine and Gerontology 7th edition (2016)
Jayna Holroyd-Leduc et al. Evidence Based Geriatric Medicine (2012)
Jeffrey B. Halter et al. Hazzard's Geriatric Medicine and Gerontology 7th edition (2016) Jayna Holroyd-Leduc et al. Evidence Based Geriatric Medicine (2012)
Elie M, Rousseau F, Cole M, et al. Prevalence and detection of delirium in elderly emergency department patients. CMAJ 2000; 163:977.
Kiely DK, Bergmann MA, Murphy KM, et al. Delirium among newly admitted postacute facility patients: prevalence, symptoms, and severity. J Gerontol A Biol Sci Med Sci 2003; 58:M441.
Mach JR Jr, Dysken MW, Kuskowski M, et al. Serum anticholinergic activity in hospitalized older persons with delirium: a preliminary study. J Am Geriatr Soc 1995; 43:491.
Campbell N, Boustani M, Limbil T, et al. The cognitive impact of anticholinergics: a clinical review. Clin Interv Aging 2009; 4:225
Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium risk factors in elderly hospitalized patients. J Gen Intern Med 1998; 13:204.
Fick DM, Agostini JV, Inouye SK. Delirium superimposed on dementia: a systematic review. J Am Geriatr Soc 2002; 50:1723.
McAvay GJ, Van Ness PH, Bogardus ST Jr, et al. Older adults discharged from the hospital with delirium: 1-year outcomes. J Am Geriatr Soc 2006; 54:1245.
Wei LA, Fearing MA, Sternberg EJ, Inouye SK. The Confusion Assessment Method: a systematic review of current usage. J Am Geriatr Soc 2008; 56:823.
Wong CL, Holroyd-Leduc J, Simel DL, Straus SE. Does this patient have delirium?: value of bedside instruments. JAMA 2010; 304:779.
Francis J, Martin D, Kapoor WN. A prospective study of delirium in hospitalized elderly. JAMA 1990; 263:1097.
Bliwise DL. What is sundowning? J Am Geriatr Soc 1994; 42:1009.
Naughton BJ, Moran M, Ghaly Y, Michalakes C. Computed tomography scanning and delirium in elder patients. Acad Emerg Med 1997; 4:1107.
Sheth RD, Drazkowski JF, Sirven JI, et al. Protracted ictal confusion in elderly patients. Arch Neurol 2006; 63:529.