Delirium

In stark contrast to the insidious and gradual onset of dementia, delirium is an acute change often associated with inattention, confusion, and/or a clouding of the senses (Larson, 2019) 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, 2020):

• Side effects of anesthesia, 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. Preventive measures include avoiding factors known to precipitate episodes, such as polypharmacy and dehydration, and promoting situational awareness in hospitalized patients.
 
When delirium is present, the primary objective is to identify the instigating factor(s) 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, 2020).

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, 2020).
 
Pharmacologic Interventions
When delirium is manifest by disruptive behavior, especially agitation, symptom control may be necessary to allow for evaluation and treatment. A trial of psychotropic medication such as haloperidol, quetiapine, risperidone, and olanzapine may be warranted. Prescribers are urged to use the lowest dose possible of the shortest acting pharmacologic agent available. Benzodiazepines should be avoided because of their tendency to worsen confusion and delirium (Francis, 2020).

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, 2019). 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.
 
Risk Factors for Depression in the Elderly (Espinoza & Unutzer, 2019):

• Female sex
• Social isolation
• Widowed, divorced, or separated marital status
• Comorbid medical conditions
• Functional or cognitive impairment
• Insomnia
• Uncontrolled pain 

Signs and symptoms may include:

• Decreased concentration or attention span
• Impaired judgement
• Self-reported memory loss
• Feelings of hopelessness, often worse in morning
• Impaired sleep

Depressive Syndromes:

• Pathologic grief reactions (loss of spouse)
• Major or minor depression
• Dysthymic disorder

Management and Treatment (Espinoza & Unutzer, 2019):

• Psychotherapy
• Antidepressant medications
• Neurostimulation therapies
• Bright light therapy
• Exercise
• Family support

Special Considerations

The family or caregivers of those suffering with dementia may also need support, particularly during an acute illness or a combined bout of delirium. Seeing a loved one in acute delirium may leave caregivers feeling frustrated, frightened, and depleted. Consider that delirium may need weeks or months to resolve fully, and this will require care to continue in other less acute settings. Communication with family, care team, and anticipated long-term care facilities should include details about the patient’s mental status and cognitive needs.

Comparing Dementia, Delirium and Depression (Dening, 2019)
	Dementia	Delirium	Depression
Onset and duration	Slow and insidious onset Deterioration is progressive over time Permanent	Sudden onset – over hours or days Duration – hours to less than one month, but can be longer Fluctuating clinical features Usually reversible with treatment of underlying cause	Recent change in mood persisting for at least two weeks – may coincide with life changes; can last for months or years Usually reversible with treatment
Psychomotor activity	Wandering/exit seeking Agitated Withdrawn (may be related to coexisting depression)	Hyperactive delirium: agitation, restlessness, hallucinations Hypoactive delirium: sleepy, slow-moving Mixed: alternating features of the above	Usually withdrawn Apathy May include agitation
Attention	Generally normal	Impaired or fluctuates, difficulty following conversation	May appear impaired
Mood	Depression may be present in early dementia	Fluctuating emotions, for example: anger, tearful outbursts, fear	Depressed mood Lack of interest or pleasure in usual activities Change in appetite (increase or decrease)
Thinking and speech	Difficulty with word-fluency, word-retrieval, and abstraction	Disorganized, distorted, fragmented, incoherent	Intact; themes of helplessness and hopelessness present