Delirium in the Elderly

Intro & Epidemiology - Foggy Minds Alert

• Definition: Acute onset, fluctuating course, disturbed attention & awareness, cognitive issues (memory, orientation, language, perception).
• Epidemiology: Common in elderly; 10-30% of hospitalized older adults, up to 50% post-surgery.
• Significance: Leads to ↑ morbidity, ↑ mortality, ↑ length of stay, and ↑ institutionalization rates.

⭐ Delirium is a medical emergency and often the first sign of a serious underlying illness in the elderly.

Etiology & Pathophysiology - Brain Under Siege

• Predisposing Factors: Age >65 yrs, pre-existing dementia, sensory impairment (vision/hearing), polypharmacy (≥5 drugs), severe illness, multiple comorbidities (renal/hepatic failure, CVA).
• Precipitating Factors: 📌 I WATCH DEATH (Infection [UTI, pneumonia], Withdrawal [alcohol, BZDs], Acute metabolic [electrolytes, glucose], Trauma, CNS pathology, Hypoxia, Deficiencies [B12, thiamine], Endocrinopathies, Acute vascular, Toxins/Drugs, Heavy metals).
• Common Offending Drugs: Anticholinergics, benzodiazepines, opioids, TCAs, H2 blockers.
• Pathophysiology: Central cholinergic deficiency (↓ACh), dopamine excess (↑Dopamine), inflammation (cytokines), stress cortisol response.

⭐ Polypharmacy is a major reversible risk factor for delirium in geriatric patients.

Clinical Features & Diagnosis - Confusion Unmasked

• Core Features: Acute onset, fluctuating course, inattention (e.g., ↓digit span), disorganized thinking, altered Level of Consciousness (LOC).
• Motor Subtypes:
  • Hyperactive: Agitation, restlessness.
  • Hypoactive: Lethargy, ↓motor activity (often missed).
  • Mixed. | Delirium Type | Features | Prognosis (Elderly) | | :------------ | :------------------------------------- | :------------------ | | Hyperactive | Agitation, restlessness, vocalizations | Variable | | Hypoactive | Lethargy, ↓activity, quiet, withdrawn | Poorer, often missed|
• Associated: Perceptual disturbances (visual hallucinations common), sleep-wake cycle disruption, emotional lability.
• Diagnosis: DSM-5 criteria. 📌 CAM (Confusion Assessment Method): Requires (1. Acute onset & fluctuating course AND 2. Inattention) WITH EITHER (3. Disorganized thinking OR 4. Altered LOC).

⭐ Hypoactive delirium is more common in the elderly but often underdiagnosed, leading to poorer outcomes.

Differentials & Workup - Ruling Rivals Out

• Key Differentials: Dementia (gradual), Depression (pseudodementia, "don't know"s), Psychosis (primary vs. induced).
• Delirium vs. Rivals:

  Feature	Delirium	Dementia	Depression (Pseudo)
  Onset	Acute	Gradual	Variable
  Course	Fluctuating	Progressive	Diurnal variation
  Attention	↓↓	↓ (late)	↓ (concentration)
  Consciousness	Clouded	Clear	Clear

• Workup:
  • History: Collateral crucial, baseline cognition.
  • Exam: Full physical, neuro, vitals.
  • Labs: FBC, U&Es, LFTs, glucose, Ca, TFTs, B12/folate, CRP/ESR, cultures, UA, ECG.
  • Consider: CXR, CT/MRI brain (focal/trauma/unclear), LP (infection?), EEG (slowing).

⭐ A key differentiator between delirium and dementia is the acute onset and fluctuating course of symptoms in delirium.

Management & Prevention - Clearing the Fog

• Primary goal: Identify & treat underlying cause(s).
• Non-pharmacological (first-line):
  • Supportive care (hydration, nutrition), environmental modification (quiet, well-lit).
  • Reorientation (calendars, clocks), sleep promotion.
  • Early mobilization, address sensory deficits (glasses, hearing aids).
• Pharmacological (severe agitation/psychosis posing risk):
  • Low-dose antipsychotics: Haloperidol 0.25-0.5 mg, Risperidone 0.25-0.5 mg.
  • ⚠️ Avoid benzodiazepines (unless alcohol/sedative withdrawal).
• Prevention:
  • 📌 HELP (Hospital Elder Life Program): Cognitive stimulation, sleep protocols, mobility, vision/hearing aids, hydration.

⭐ Non-pharmacological multicomponent interventions are the cornerstone of delirium management and prevention.

High‑Yield Points - ⚡ Biggest Takeaways

• Acute onset, fluctuating course, and inattention are core features.
• Precipitated by infections (esp. UTI), polypharmacy, metabolic derangements.
• Hypoactive delirium is often missed and more common in elderly.
• EEG shows generalized slowing of background activity.
• Management: treat underlying cause, provide supportive care.
• Low-dose haloperidol for severe agitation (use cautiously).
• Prevention by addressing risk factors (dehydration, immobility, sensory impairment) is key.