Delirium
In stark contrast to the insidious and gradual onset of dementia, delirium is an acute change often associated with confusion or a clouding of the senses (Larson, 2017) and should be considered a medical emergency. Delirium is a complex neuropsychiatric syndrome which tends to develop over a period of hours or days and may fluctuate throughout the course of a day (Paulo et al., 2017).
Signs and symptoms may include:
- Inability to focus, sustain attention, or shift attention between tasks
- Hypervigilance
- Agitation and restlessness
- Tremulousness
- Hallucinations (visual, auditory, tactile)
- Somnolence, decreased mental status, hypoactivity
Delirium may be precipitated by (Francis, 2014):
- Side effects of medication, or interactions of medications
- Intoxication with prescribed medication due to accumulated doses
- Infections, such as sepsis, pneumonia, or urinary tract infections
- Dehydration
- Electrolyte imbalances, including hypoglycemia
- Metabolic disturbances including hypoxemia and hypercarbia
- Sleep disturbances, insomnia due to hospitalization
- Immobilization, altered care setting, lack of usual assistive devices for mobilization
- Sensory impairment, not having glasses or hearing aids available
Treatment and Management
Avoiding delirium in the elderly is the best approach, and this includes avoiding factors known to precipitate episodes, such as polypharmacy and dehydration.
When delirium is present, the primary objective is to identify the instigating factor and provide definitive treatment. While caring for the patient with acute delirium, non-pharmacologic measures offer the safest care options allowing the primary cause time to resolve. Providing a supportive and restorative setting, with respect for hours of sleep, limiting sensory overload, and creating a home-like setting are known to decrease the incidence and duration of delirium in the highest risk patients (Francis, 2014).
Nonpharmacologic Interventions
- Altering patient environment, decreasing ambient noise, improving lighting.
- Providing frequent reassurance through touch and verbal reorientation.
- Using familiar staff or family to reassure and observe patient.
- Neither endorsing nor challenging hallucinations or delusions.
It is recommended that physical restraints are avoided, as they contribute to poor physical outcomes (aspiration, lost mobility, pressure ulcers), prolonged duration of delirium, and are not proven to be effective (Francis, 2014).
When appropriate and necessary, prescribers are urged to use the lowest dose possible of the shortest acting pharmacologic agent to allow the non-pharmacologic treatments to be successful in easing the bout of delirium.
Depression
Depression can present as a confounding factor when examining elderly patients suffering from cognitive decline. Elderly patients with depression will often be able to self-report that they are experiencing memory problems, and may make weak attempts to perform cognitive exams, stating “I just can’t do this” (Larson, 2017, p.3). Depression may affect anyone, and the elderly are no exception. Those with baseline dementia may also suffer from depression, and it is therefore recommended that clinicians screen for depression in the elderly, as it is a treatable/reversible comorbid condition that can contribute to dementia and cognitive decline.
Signs and symptoms may include:
- Decreased concentration or attention span
- Impaired judgement
- Self-reported memory loss
- Feelings of hopelessness, often worse in morning
Depressive Syndromes
- Pathologic grief reactions (loss of spouse)
- Major or minor depression
- Dysthymic disorder