Delirium is a common occurrence in hospital and community settings, with prevalence rates of 10-40% (APA Practice Guideline 1999, Siddiqi 2006) and 1-2% (Cole 2004) respectively. It is an independent cause for increased morbidity and mortality in elders, especially if under-recognized or under-treated (Inouye 2006). It is regarded as a medical emergency. It is under-recognized in 32-66% of cases (Inouye, 1998), especially in those over 80 years old, with hypoactive delirium, with visual impairment, and/or pre-existing dementia (Inouye 2001). This under-diagnosis can also occur in complex or long term care nursing facilities (Voyer 2008). It is primarily a disturbance of consciousness, attention, cognition, and perception (APA DSM IV-TR), which can be sometimes difficult to distinguish from other common geriatric mental disorders such as dementia (MacDonald, 1996) and depression. The consequence of this disturbance can lead to aggression, paranoia, disturbing hallucinations, and intense restlessness. The full syndrome of Delirium is created from a global disturbance in mental functioning, and the hallmark is a fluctuation in this disturbance over the course of a day. There is no unifying hypothesis to how this occurs, but some have postulated disruption in cerebral cortical metabolism (Engel and Romano 1959) or excessive anticholinergic changes in the brain (Tune, 2001). Localized brain regions such as the posterior parietal cortex, the prefrontal cortex, and the thalamus seem to be important regions that mediate the development of delirium (Trzepacz 1996). This may have an effect on the reticular activating system in the brainstem, which governs level of alertness and attention, and the autonomic nervous system, which can lead to hyper-arousal of sensory and motor systems (Lipowski, 1980).
While recognition and treatment of the underlying medical cause(s) precipitating the onset of delirium is paramount, the management of the delirium itself involves a holistic, interdisciplinary approach. Addressing environmental, psychological, social, and family needs are essential when a delirious person is identified. Delirium is associated with poorer functional recovery (Marcantonio, 2003), so normalizing physiologic functions such as sleep habits, and maintaining functional abilities in the areas of mobility and toileting, can be important to a better outcome in a delirious senior. Identifying and stopping medications which can trigger delirium is important. Judicious use of psychotropic medications to treat behavioural and sleep-wake disturbances arising from delirium may be indicated. Although Delirium is regarded as a “reversible” mental syndrome which disappears once precipitating and perpetuating factors are addressed, only 4% to 40% of elderly individuals are deemed fully recovered upon discharge (APA Practice Guidelines, 1999). They often have persistent cognitive and functional deficits despite specialized interventions (O’Keefe, 1997a, McCusker 2003).
The rest of the pre-reading for this module will detail these issues. The case will highlight some of the challenges and dilemmas when dealing with a potentially delirious senior in both community and hospital settings. It is designed to explore the interdisciplinary team’s roles and relationships in the course of managing delirium in an elder. Each member of the team brings their unique skill set and knowledge base to the assessment and management planning. However, there is also often role overlap between the disciplines and each part of the care plan may be managed by several individuals. In some instances, not all disciplines are represented on a team. Both the unique skill sets as well as the different approaches at assessing the issues often strengthens the delirious person care plan and provides a more complete approach to addressing the needs of the ill senior. This module does not focus on the management of delirium in ICU (Girard 2008) or palliative care settings (Breitbart 2008), which are reviewed elsewhere.