Delirium, a common acute condition with significant short- and long-term effects on cognition and function, should be identified as an indicator of poor long-term prognosis, prompting immediate and effective management strategies, according to the authors of a new systematic evidence review.
“Delirium is extremely common among older adults in intensive care units and is not uncommon in other hospital units and in nursing homes, but too often it’s ignored or accepted as inevitable. Delirium significantly increases risk of developing dementia and triples likelihood of death. It can’t be ignored,” said Regenstrief Institute investigator Babar A. Khan, M.D., M.S., assistant professor of medicine at the Indiana University School of Medicine and an Indiana University Center for Aging Research scientist, the first author of the review.
The authors reviewed 45 years of research encompassing 585 studies to provide a roadmap for the identification of risks, prevention and treatment options as well as prognoses related to delirium.
“As an intensive care unit physician, I have seen that about 80 percent of ICU patients who need mechanical assistance to breathe develop delirium,” Dr. Khan said. “That’s because in addition to being on a respirator, they have multiple risk factors that can predispose and precipitate delirium, including but not limited to serious illness, restraints and pre-existing cognitive impairment.”
According to the American Delirium Society, more than 7 million hospitalized Americans suffer from delirium each year, and more than 60 percent of delirium cases are not recognized or treated.
“Having delirium prolongs the length of a hospital stay, increases the risk of post-hospitalization transfer to a nursing home, increases the risk of death and may lead to permanent brain damage,” said Regenstrief Institute investigator Malaz Boustani, M.D., MPH, associate professor of medicine at IU School of Medicine and associate director of the IU Center for Aging Research. Dr. Boustani, senior author of the new study, is medical director of the Wishard Healthy Aging Brain Center and president of the American Delirium Society.
What is delirium?
Delirium (or new mental confusion) is a sudden change in mental status, or sudden confusion, which develops over hours to days. It is different from dementia, such as Alzheimer’s disease, which is a chronic confusional state that develops and progresses over time.
Features of delirium
Delirium causes consciousness to become clouded and makes paying attention or focusing thoughts difficult. Some people hallucinate or become paranoid because of difficulty with interpreting the environment. Other symptoms may include rambling speech and jumbled thoughts. These symptoms tend to come and go during the course of the day. Confusion regarding day-to-day events, daily routines, and the roles of familiar people is common. Changes in personality can occur. Some persons become quiet and withdrawn while others become agitated or hyperactive. Normal patterns of sleeping and eating are often disrupted.
How to lower the likelihood of delirium and increase recognition of cases that occur? Drs. Khan and Boustani recommend eliminating restraints, treating depression, ensuring that patients have access to eyeglasses and hearing aids, and prescribing classes of antipsychotics that do not negatively affect the aging brain. They and the other study authors note the need for a more sensitive screening tool for delirium, especially when administered by a non-expert.
Delirium is a common condition affecting ill older people, especially those with some degree of dementia
• Delirium is a medical emergency which is an acute and fluctuating onset of confusion, disturbances in attention, disorganized thinking and/or decline in level of consciousness
– Presentation can vary from hyperactive to hypoactive to mixed
• It’s the most common complication of hospital admission for older people, prevalence …
– Lowest rates in community, about 1%
– Hospitalized, about 7-38% (emergency department 24%)
– Long-term care, about 64%
“Delirium in Hospitalized Patients: Implications of Current Evidence on Clinical Practice and Future Avenues for Research – A Systematic Evidence Review” was published in the September issue of Journal of Hospital Medicine. In addition to presenting evidence for clinical practice, it identifies areas for future delirium research.
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The study was supported by the National Institute on Aging (grant AG054205-02) and the National Institute of Mental Health (grant MH080827-04).
In addition to Drs. Khan and Boustani, authors of the paper are Mohammed Zawahiri, M.D., of the Regenstrief Institute and IU Center for Aging Research; Regenstrief Investigator Noll L. Campbell, Pharm.D., of Purdue University and Wishard Health Services; George C. Fox, M.D., MRCPsych, University of East Anglia, Norfolk, U.K.; Eric J. Weinstein, M.D., of Tri-State Pulmonary Associates, Cincinnati, Ohio; Arif Nazir, M.D., Mark O. Farber, M.D., and John D. Buckley, M.D., MPH, of the IU School of Medicine; and Alasdair MacLullich, Ph.D., of the University of Edinburgh.
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Cindy Fox Aisen
caisen@iupui.edu
317-843-2276
Indiana University School of Medicine