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Unique To Older Adults > Delirium > Aging & Health A To Z > Health in Aging

Aging & Health A to Z

Delirium

Unique to Older Adults

This section provides information to help older adults and their caregivers consider their disease or condition in conjunction with other health issues.
As older adults live longer, they may have more than one chronic disease.  Or, they may have a health problem that can lead to another condition or injury if not properly managed.   The older adult may also experience healthcare in various settings, such as the hospital, assisted living facility or at home. These situations can affect the health and function of the older adult and therefore require careful management to ensure proper care and improve or maintain quality of life.

Alzheimer’s Disease and Other Types of Dementia

Many older people develop a condition of cognitive or mental decline called dementia. Some of the causes of dementia in older people include:

• Alzheimer’s disease
• Vascular dementia
• Lewy body dementia
• Multi-infarct dementia (many tiny strokes, also called transient ischemic attacks or TIAs)
• Parkinson’s disease.

In general, delirium is characterized by the development over a short time period of confusion or inability to think clearly.  People with dementia have a high risk of developing delirium. Symptoms of delirium can overlap with symptoms of dementia, with the result that healthcare workers may not recognize that a patient with dementia has developed delirium.
Signs that a patient with Alzheimer’s disease or another type of dementia has become delirious include:

• Sudden change in behavior (not more gradually as in Alzheimer’s disease)
• Increased agitation or confusion
• Confusion varies during the day, at some times much worse than at other times
• Disorganized thinking – inability to have a conversation
• Either “hyperalert” (extremely alert) or “hypoactive” (drowsy, less responsive)
• Inability to focus on one thing – lack of attention.

If you suspect that someone in your care with Alzheimer’s disease has become delirious, you must alert a healthcare professional. Delirium may be caused by many things.  One of the most common causes of delirium is medications, especially a reaction to a new medication.  Among the most common medications that cause delirium are narcotics, benzodiazepines, anti-cholinergic medications, anti-Parkinsonian drugs, and some anti-epileptic medications.  Acute infection, surgery, or a new illness are other common causes..
Although it is difficult to distinguish between delirium and dementia, it is important for your healthcare professional to do so because delirium is reversible if treated promptly. Three of the key signs that a patient is delirious are:

• You cannot get their attention
• Immediate changes in behavior, personality, or temperament
• A change is someone’s level of consciousness (for example, hyperalert or drowsy).

Stroke or Vascular Dementia

Sometimes people who suffer strokes develop delirium.  This can occur without any other medical complications and regardless of whether the stroke was caused by a blood clot or a hemorrhage.
Delirium in Parkinson’s disease, Lewy Body and other Parkinson’s DementiasPeople with Parkinson's disease are at high risk for developing delirium. Delirium in these patients can be a sign of advancing disease.  Some drugs taken to control Parkinson’s disease may also bring on delirium in some patients.
Lewy body dementia is named after the abnormal Lewy body structures that appear in the brains of people suffering from this disease. Lewy body dementia produces symptom of dementia, signs of parkinsonism, and psychiatric disturbances, such as hallucination and behavioral troubles.  In addition, patients with this problem will often develop delirium without apparent underlying cause.

Depression

Delirium and depression both happen more often than they are noticed in older people, sometimes at the same time. Depression can be triggered by many of the same medical problems that can cause delirium, such as heart disease, cancer, chronic lung disease, stroke, Parkinson’s disease, or dementia.
It is important to tell whether someone has depression, delirium or both, because the treatments are different for each one. A good clue that someone may be suffering from delirium and not depression is if the low mood or energy symptoms appear quickly. Depression tends to come on more slowly and persist for a long time unless it is treated. Patients who are depressed are also more likely to report that their memory is getting worse, while people with delirium or dementia may not notice or believe they are having memory problems.
Older persons who have both depression and delirium have more problems with their judgment because they are both suffering and confused.  This means that they may be more likely to act on a suicidal thought, and should not be left alone if at all possible.

Urine Retention or Fecal Impaction

Among the many reversible causes of delirium, urine retention and fecal impaction are much more common in older people. Both of these conditions cause discomfort, but if the patient is delirious, he or she will not be able to explain the situation.
If you are caring for an older person, make sure to monitor frequency of urination and bowel movements. Usually, urine retention can be treated with temporary installation of a urinary catheter. Enemas, mild laxatives, and subsequent stool softeners will usually resolve the situation. Careful attention to diet and exercise afterward will help to prevent an impaction from recurring. 

History of Alcohol or Substance Abuse

Delirium may be a symptom of alcohol or drug (e.g. benzodiazepine, opioid)withdrawal if someone who is dependent on it stops consuming it suddenly.  Delirium may also occur when taking illegal drugs like cocaine, LSD, PCP, or amphetamines, or as an adverse effect of particular medications. The healthcare professional treating the patient must be told exactly which drug the delirious patient has taken to make sure that treatment is appropriate.
Some of the symptoms of delirium that are possible during severe alcohol withdrawal or substance abuse include:

• Shaking and trembling (tremors). 
• Changed mental functions like delirium, agitation, excitement, irritability, confusion, restlessness
• Shorter attention span
• Deep sleep lasting a full day or longer; general sleepiness, fatigue
• Insomnia
• Hallucinations
• Sudden mood changes, including anxiety, depression, nervousness
• Extra sensitivity to light, sound, touch
• Seizures (epileptic-type fits)
• Headache
• Loss of appetite or nausea and vomiting
• Heavy sweating
• Heart palpitations (fast, sometimes uneven heartbeat). 

Delirium is a medical emergency that must be treated in hospital. Call your healthcare professional right away if someone you care for is experiencing symptoms of this dangerous condition. 

Delirium and Functional Impairment

If an older patient is suddenly—over a period of hours—unable to cope with the everyday functions of daily life, you should suspect that he or she may be suffering from delirium. This is particularly the case if the person is also depressed or suffering from dementia.
When a patient who has recently had surgery becomes delirious, his or her chances of recovering full function in their daily life are much worse than if they do not have delirium.  About 40% of older surgical patients develop delirium after surgery.
Because delirium occurs so often after surgery in older patients, and since it raises the risk of poor functioning afterwards, it is extremely important to identify and correct and treat the factors that have brought it on. 

Infections or Sepsis:  Respiratory, Urinary, Skin

Sometimes, a bacterial infection can cause delirium. When bacteria (germs) invade your body.  You may be at particular risk if you develop sepsis which is a bacterial infection of your blood. Sepsis may sometimes occur after an operation, or it may develop from an infection in another part of your body. Delirium may also result from a fever caused by a bacterial or a viral infection such as West Nile virus. Delirium is a strong indicator that a person has developed sepsis, and most often appears before the infection has been discovered.
The infections that are most often linked to delirium include urinary tract infections (infections in your bladder or kidneys), lung infections (pneumonia) or skin infections (from skin ulcers or serious infections by drug-resistant bacteria).  

Medications

Some medicines commonly used in older adults can cause delirium in susceptible people. You must be particularly careful in the case of recently-started drugs taken to control depression, anxiety, or other mood or mental disorders.
Drugs that are known to cause delirium in some people include:

• anticholinergic drugs (taken to slow down Alzheimer’s disease)
• some antidepressants (such as tricyclic antidepressants)
• anti-epileptic medicines and barbiturates
• sedatives and hypnotics like benzodiazepines (i.e., Valium)
• sleep medications
• pain relievers containing narcotic drugs
• lithium
• some allergy medicines, such as Benadryl
• some anti-Parkinson’s medicines
• digestive remedies such as H2 receptor blockers, anti-spasmodics, and anti-nausea drugs
• antibiotics in the fluoroquinolone class (such as Cipro or Levaquin)
• heart medicines such as digitalis or beta blockers. 

You should avoid these types of medicines whenever possible, or take the lowest effective doses available.

Hospitalization or Environmental Change

Delirium is extremely common in older adults who have become hospitalized. Delirium is a well-known adverse effect of surgery, and is often evident in patients in the intensive care unit, or in long-term care institutions. As a person’s cognitive awareness begins to decline they may be prone to experiencing delirium if hospitalized.  The absence of a familiar environment, recognizable family members, or even the frequent room changes that often occur in hospitals all increase the disorientation that may lead to an episode of delirium.
To decrease the risk and chances of delirium, try to make sure the person you are caring for has:

• eyeglasses and hearing aids if these are normally used
• a clock or watch in easy view
• the name of the doctors and nurses written clearly in sight
• plenty of light during the day (preferably a window with natural light)
• quiet and subdued light or darkness at night
• a family member or friend present whenever possible. 

Pain

Delirium occurs most often in hospital recovery units where patients are placed after general surgery. Pain management is of particular concern in these situations and it is importance that the patient communicates with their doctors if they experience pain. Unrelieved pain itself may bring on delirium. If the older person has difficulty hearing, this may make it harder to inform caregivers of the severity and degree of pain the patient is in. Hearing aids should always be worn (if possible) to establish clear communication while in recovery.
Researchers have found that patients who receive greater amounts of pain medicine after an operation are less likely to become delirious, or if they do experience delirium, it will be milder and take longer to appear. These medications include: morphine, hydrocodone, tramadol, and  other well-known pain drugs.
Falls and FracturesDelirium itself may cause a fall. This is due to the confusion, excitability, inattention, and misunderstanding of environmental cues that occur when a person experiences delirium.  When you get older, your risk of a fall increases. There are many reasons for the increased risk—including balance problems, weak muscles, lack of exercise, general frailty, sudden low blood pressure, malnutrition, and weak, thinning bones (osteoporosis). If you fall, particularly if you have osteoporosis, you may fracture a bone. Common fractures are those of the hip, wrist, or a bone in the back (vertebra). 

Hearing and Vision Deficits

Poor hearing can put you at higher risk for delirium. Not being able to communicate or understand verbal interactions places an older person in a frustrating and isolated state. This can have a detrimental effect on mental functions. If you or someone you are caring for is hard of hearing, make sure to use hearing aids and let healthcare professionals know that you have hearing loss.
Similarly, older people who need eyeglasses or who have impaired vision must make sure that their healthcare providers are aware of the difficulty seeing. If you are going to stay in hospital, take your glasses with you and use them so that you are able to see your environment, the clock, and the individuals caring for you. To avoid episodes of delirium, it is important to be as aware and as comfortable as possible in the stressful environment of the hospital.

Dehydration

You may be less aware that you are dehydrated (suffering from lack of fluids in your body) than before. This is because older people tend not to feel thirsty as readily as they did when they were younger, even though older people tend to have less fluids in their bodies.
A leading cause for dehydration among older adults are water pills (diuretics). These pills cause frequent urination.  In addition to not feeling thirsty, older people may also be at higher risk of dehydration because many take water pills for high blood pressure (diuretics). These pills cause frequent urination. Drinking coffee, tea, or alcohol also causes water to be lost from your body, since these beverages encourage urination. Fever, hyperventilation or diabetes are also capable of causing water loss, as are problems in the digestive tract. Unfortunately, dehydration often goes unrecognized in frail older people.
Being dehydrated puts you at increased risk for becoming delirious. To stay hydrated, drink plenty of fluids and eat foods that contain large amounts of fluids, such as melon and organs. Be particularly vigilant if you are taking water pills (diaretics). Urine that appears darkly colored may indicate that you are dehydrated.

Electrolyte Abnormalities: Hyponatremia, Hypernatremia

As you age, your body loses its ability to keep the amount of water in your body steady (water homeostasis). Specifically, the hormones that keep the salt (sodium) and water balance healthy may not longer work well. You may develop hyponatremia (low sodium level in your blood) or hypernatremia (high sodium level). These two conditions are especially common in nursing homes or hospitals.
HyponatremiaThis may result from excessive fluids given through an IV and insufficiently monitored. Also, your kidneys are less efficient than when you were younger, and therefore, sodium balance is easier to upset in an older person. Also, some drugs are linked to hyponatremia (hydrochorothiazides).
If you experience hyponatremia, you may become confused and exhibit a state similar to delirium. However, usually hyponatremia is a mild condition, and can be controlled by restricting fluids and stopping any medicines that may be making the condition worse. Then the underlying cause – be it kidney disease, heart failure, cirrhosis, or some other illness – must be treated promptly.
HypernatremiaThis condition is usually caused by lack of adequate fluid intake.  Hypernatremia can affect your central nervous system and cause symptoms such as:

• restlessness and irritability
• fatigue and lethargy
• muscular twitching, increased reflexes
• delirium. 

Hypercalcemic Disorders

Older people often develop hyperparathyroidism—an overactive parathyroid gland (a gland in your neck). When this happens, you may develop higher than normal levels of calcium in your blood—a condition known as hypercalcemia.
If the calcium levels are only slightly higher than normal, you probably will have no symptoms. However, if the calcium rise to higher levels, delirium may occur, along with nausea, vomiting, fatigue, or confusion.
Hypercalcemia may also stem from a cancerous tumor. Therefore, if you or a loved one exhibits the type of symptoms listed, you must call your doctor promptly.
Hyperparathyroidism is more common in women, especially those over the age of 65 years.

Surgery/Anesthesia

Surgery in hospital is a major cause of delirium in older people, causing this condition in two and a half million older Americans each year. This type of delirium—often referred to as “post-anesthesia delirium—is still not well understood. It usually appears in about one out of 10 older patients after surgery.
When delirium occurs after surgery, patients usually have to stay in hospital longer. Many go home still experiencing symptoms of delirium. For some patients, the delirium requires them to be placed in a long-term care facility. There is a higher risk of developing memory loss, mental (cognitive) decline, and dementia in these older patients, and an increased risk of death compared to patients who do not experience delirium after an operation. Often these effects are long-lasting.
It is known that some inhaled anesthetics, such as isoflurane, can trigger Alzheimer’s disease-type changes in the brain. There does not appear to be any difference whether a general anesthetic or a more local one is used.

Updated: March 2012
Posted:  March 2012