Definition and Risk Factors
Delirium: acute, fluctuating disturbance of attention and cognition, caused by a medical condition. NOT dementia (which is chronic, progressive). Prevalence: 20-40% of hospitalized elderly, 50-80% ICU. Risk factors: age >70, dementia, surgery (hip, cardiac), infection, medications, sensory impairment, dehydration, restraint use, environmental changes. Mortality: 10-26% in hospitalized elderly with delirium.
Assessment
CAM (Confusion Assessment Method): 1) acute onset and fluctuating course, 2) inattention, 3) disorganized thinking, 4) altered level of consciousness. Features 1 and 2 must be present plus 3 or 4. RASS (Richmond Agitation-Sedation Scale) for severity. Differentiate from dementia: acute vs chronic, fluctuating vs progressive, inattention vs intact attention. Assess for causes: infection (UTI, pneumonia), medications (anticholinergics, benzodiazepines, opioids), metabolic (Na, Ca, glucose, BUN), hypoxia, pain, constipation, urinary retention, sleep deprivation.
Nursing Management
Treat underlying cause. Non-pharmacological: orient (clock, calendar, familiar objects), re-establish sleep-wake cycle (lights, minimize night interruptions), family at bedside, sensory aids (glasses, hearing aids), early mobilization, adequate hydration and nutrition, pain control, minimize medications (review anticholinergics, benzodiazepines), minimize restraints (use alternatives). Pharmacological: haloperidol or atypical antipsychotics for severe agitation ONLY (not for routine management). Monitor for complications: falls, pressure injuries, aspiration, prolonged hospitalization.
Important Notes
- Delirium is acute and fluctuating; dementia is chronic and progressive — a common diagnostic error is mislabeling delirium as dementia.
- CAM requires features 1 (acute onset) and 2 (inattention) plus either 3 (disorganized thinking) or 4 (altered consciousness).
Clinical Tips
- Delirium increases mortality, length of stay, and institutionalization — early recognition and treatment of underlying causes is critical.
- Avoid anticholinergics, benzodiazepines, and unnecessary medications in elderly — they precipitate delirium.
Summary
Delirium in older adults requires CAM assessment, identifying and treating underlying causes, non-pharmacological management (orientation, sleep, family, mobilization), and minimizing medications.
