Perspectives on delirium in the elderly
Received Date: Jan 13, 2018 / Accepted Date: Feb 18, 2018 / Published Date: Feb 20, 2018
Citation: Cerveira CCT. Perspectives on delirium in the elderly. Clin Psychol Cog Sci 2018;2(1):19-20.
This open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) (http://creativecommons.org/licenses/by-nc/4.0/), which permits reuse, distribution and reproduction of the article, provided that the original work is properly cited and the reuse is restricted to noncommercial purposes. For commercial reuse, contact [email protected]
Delirium is a neurobehavioral syndrome related to some systemic disorder. It is characterized by an acute onset, fluctuating course and changes in orientation, memory, attention and behavior. In the elderly, its incidence reaches 50% of hospitalizations, being associated to an increase in length of hospital stay, admission rates in long-stay institutions, functional disorders and mortality, which substantially increases health and social care costs [1,2].
The diagnosis of delirium is eminently clinical and the knowledge of previous baseline mental status of the patient is crucial for it.
There are two clinical presentations of the syndrome: hyperactive and hypoactive forms (patients can oscillate between them). The hypoactive form is more common in the elderly and leads to higher rates of complications and mortality. Although its relevance, about 84 to 95% of delirium cases are not diagnosed by attending physicians . The most commom instrument used for diagnosis is the Confusion Assessment Method (CAM) and its variations . Delirium detection, prevention and management have been used as indicators of quality care of hospitalized older patients .
Several studies have shown the importance of its prevention through the early detection of risk factors such as previous cognitive deficit (major risk factor), history of alcohol abuse, age greater than 70 years, polypharmacy, severity of the underlying disease, infections, fractures and physical restrictions [4-6]. The treatment of the basic medical condition is of fundamental importance for the resolution of sthe syndrome.
There is no definitive treatment for delirium and lack of evidence from randomized controlled trials on this field specially considering trials that exclusively includes patients over 60 years.
There is evidence that non-pharmacological treatments based on screening, geriatric consultation, staff education, changes in the environment, pharmacological protocols, presence of family or volunteer, nursing protocols for risk factors and behaviour management, are effective in reducing the incidence of delirium [2,7,8]. but once it is established the evidence base remains limited [2,3,7]. Lundström et al obtained a reduction in the duration of delirium, length of hospital stay and mortality with an educational program and reorganization of the heath service , but these results were not replicated in other studies [2,3,7,10,11]. Two recent systemic reviews found that non-pharmacological treatment for established delirium had no benefit on duration, severity and mortality but showed an improvement in patient’s functional status [12,13].
Most of the non-pharmacological trials uses a group of interventions simultaneously and a multiprofessional approach, so it is not possible to evaluate if one of them is more effective than another. It is the set of them that lead to the results.
There is no consistent evidence that the pharmacologycal treatment reduces the incidence of delirium and it is not recommended for the prevention of the syndrome .
The use of pharmacologic treatment for established delirium is accepted for agitated patients that can cause harm for itself or others, but it is controversial in other settings. The antipsychotics are the drugs of choice. A systematic review compared typical antipsychotics (haloperidol) with atypical antipsychotics (amissulpride, quetiapine, olanzapine and risperidone) for the treatment of delirium and found that there was no difference of effectiveness between them .
Only few trials tested drugs other than antipsychotics for the treatment of established delirium (melatonin, ramalteon and cholinesterase inhibitors) with no benefits on duration and mortality, but the samples were small, and evidence of larger studies are necessary [15,16]. Benzodiazepines should not be used in delirious patients, exception for cases of alcohol withdrawn and abstinence of benzodiazepines, after physician judicious evaluation.
Delirium still a challenge for all the medical and health staff. The efforts should lay on educational programs, prevention and early detection. Patient’s family has an important role on the perception of a change on patient’s mental base state and contribute to its recovery, so it should not be left aside of the medical decisions. New scientific evidence from randomized controlled trials specially with a population >60 years are needed for further protocols and management of established delirium.
Conflicts of Interest
- Inouye SK, Westendorp RG, Saczynski JS. Delirium in the elderly people. Lancet 2014; 383(9920):911-22.
- Cole MG, Primeau FJ, Bailey RF, et al. Systematic intervention for elderly inpatients with delirium: A randomized trial. CMAJ 1994;151(7):965-70.
- Cole MG, McCuster J, Bellavance F, et al. Systematic detection and multidisciplinary care of delirium in older medical inpatients: A randomized trial. CMAJ 2002;167:753-9.
- Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990;113(12):941-8.
- Inouye SK. Delirium in older persons. N Engl J med 2006;354:1157-65.
- Vidan MT, Sanchez E, Alonso M, et al. An intervention integrated into daily clinical practice reduces the incidence of delirium during hospitalization in elderly patients. J Am Geriatr Soc 2009;57:2029-36.
- Mudge AM, Mussen C, Duncan J, et al. Improving quality of delirium care in a general medical service with established interdisciplinary care: a controlled trial. Intern Med J 2013;43:270-7.
- Inouye SK, Bogardus ST JR, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-76.
- Lundström M, Edlund A, Karlsson S, et al. A multifactorial intervention program reduces the duration of delirium, length of hospitalization and mortality in delirious patients. Journal of the American Geriatrics Society 2005;43:491-495.
- Pitkala KH, Laurila JV, Strandberg TE, et al. Multicomponent geriatric intervention for elderly inpatients with delirium: A randomized controlled trial. J Gerontol A Biol Sci Med 2006; 61:176-81.
- Marcantonio ER, Bergmann MA, Kiely DK, et al. Randomized trial of a delirium abatment program for postacute skilled nursing facilities. J Am Geriatr Soc 2010;58:1019-26.
- Cerveira CT, Pupo CC, Santos SDS, et al. A systematic review of pharmacological and non-pharmacological treatments. Dement Neuropsycol 2017;11(3):270-75.
- Oh ES, Fong TG, Hshieh TT, et al. Delirium in older persons. Advances in diagnosis and treatment. JAMA 2017;318(12):1161-74.
- Wang HR, Woo YS, Balk WM. Atypical antipsychotics in the treatment of delirium. Psychiatry Clin Neurosci 2013;67:323-31.
- Overshott R, Vernon M, Morris J, et al. Rivastigmine in the treatment of delirium in older people: a pilot study. Int Psychogeriatr 2010;22:812-8.
- Chakraborti D, Tampi DJ, Tampi RR. Melatonin and Melatonin Agonist for delirium in the Elderly Patients. American Journal of Alzheimer’s Desease & Other Dementias 2015;30:119-29.