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Delirium in Older Persons
Delirium in Older Persons
review article
Current Concepts
D
elirium, an acute decline in attention and cognition, is a com- From the Department of Medicine, Har-
mon, life-threatening, and potentially preventable clinical syndrome among vard Medical School, Boston. Address
reprint requests to Dr. Inouye at the Ag-
persons who are 65 years of age or older. The development of delirium often ing Brain Center, Hebrew Senior Life,
initiates a cascade of events culminating in the loss of independence, an increased 1200 Centre St., Boston, MA 02131.
risk of morbidity and mortality, and increased health care costs.1-6 Delirium in hos-
N Engl J Med 2006;354:1157-65.
pitalized older patients has assumed particular importance because the care of such Copyright © 2006 Massachusetts Medical Society.
patients accounts for more than 49 percent of all hospital days.7 Delirium compli-
cates hospital stays for at least 20 percent of the 12.5 million patients 65 years of
age or older who are hospitalized each year and increases hospital costs by $2,500
per patient,8-10 so that about $6.9 billion (value in U.S. dollars in 2004) of Medicare
hospital expenditures are attributable to delirium. Substantial additional costs ac-
crue after hospital discharge because of the need for institutionalization, rehabili-
tation services, formal home health care, and informal caregiving.
This report examines current clinical practice in delirium, identifies areas of
controversy, and highlights areas for future research.
Acute onset
Occurs abruptly, usually over a period of hours or days
Reliable informant often needed to ascertain the time course of onset
Fluctuating course
Symptoms tend to come and go or increase and decrease in severity over a 24-hour period
Characteristic lucid intervals
Inattention
Difficulty focusing, sustaining, and shifting attention
Difficulty maintaining conversation or following commands
Disorganized thinking
Manifested by disorganized or incoherent speech
Rambling or irrelevant conversation or an unclear or illogical flow of ideas
Altered level of consciousness
Clouding of consciousness, with reduced clarity of awareness of the environment
Cognitive deficits
Typically global or multiple deficits in cognition, including disorientation, memory deficits, and language impairment
Perceptual disturbances
Illusions or hallucinations in about 30 percent of patients
Psychomotor disturbances
Psychomotor variants of delirium
Hyperactive
Marked by agitation and vigilance
Hypoactive
Marked by lethargy, with a markedly decreased level of motor activity
Mixed
Altered sleep–wake cycle
Characteristic sleep-cycle disturbances
Typically daytime drowsiness, nighttime insomnia, fragmented sleep, or complete sleep-cycle reversal
Emotional disturbances
Common
Manifested by intermittent and labile symptoms of fear, paranoia, anxiety, depression, irritability, apathy, anger,
or euphoria
lirium is often missed. Older patients should be underlying disease. All preadmission and current
aroused during rounds and evaluated daily for medications should be reviewed; even long-stand-
the hypoactive form of delirium, which is often ing medications can contribute to delirium and
overlooked. should be reevaluated. If changes in long-term
When clinicians search for the underlying cause medications are appropriate after the indications
of delirium, they need to be aware of the possibil- and risk–benefit ratios have been carefully weighed,
ity of occult or atypical presentations of many the hospital represents the ideal venue for making
diseases in the elderly, including myocardial in- these changes. A medical history must be meticu-
farction, infection, and respiratory failure, because lously obtained to detect occult alcohol or benzo-
delirium is often the sole manifestation of serious diazepine use, which can contribute to delirium.
Chronic Acute
www.nejm.org
Identify and address predisposing Provide supportive care and
Manage symptoms of delirium
current concepts
Initial evaluation Review medications Prevent complications All patients Patients with severe agitation
Obtain history (including alcohol Review the use of prescription Protect airway, prevent
Downloaded from nejm.org at UFPE on June 22, 2015. For personal use only. No other uses without permission.
Maintain patient’s mobility and
Further options self-care ability
Evaluate and Normalize sleep–wake cycle,
Order laboratory tests: thyroid-function tests, measurement of drug levels, toxicology screen,
treat as discourage naps, aim for
measurement of ammonia or cortisol levels, test for vitamin B12 deficiency and arterial
appropriate uninterrupted period of sleep
blood gas levels
for each at night
Electrocardiography
contributing At night, have patient sleep in
Neuroimaging
factor quiet room with low-level lighting
Lumbar puncture, electroencephalography
1163
The n e w e ng l a n d j o u r na l of m e dic i n e
ity (as explained at www.qualitymeasures.ahrq. The changes required to reduce the incidence of
gov/). After adjusting for case mix, higher deliri- delirium on a national scale would require shifts in
um rates would be expected to correlate with local and national policies and system-wide chang-
lower quality of hospital care. The Assessing Care es to provide high-quality care for older persons.9
of Vulnerable Elders Project has ranked delirium Supported in part by grants (R21AG025193 and K24AG00949)
among the top three conditions for which the from the National Institute on Aging.
No potential conflict of interest relevant to this article was
quality of care needs to be improved.56 Total na- reported.
tional costs related to preventable adverse This article is dedicated to the memory of Joshua Bryan In-
events are estimated to be between $17 billion ouye Helfand.
I am indebted to Dr. Joseph Agostini for his helpful review of
and $29 billion per year,57 and delirium may ac- the manuscript and to Sarah Dowal and Patty Fugal for their
count for at least a quarter of these costs.53,54,57,58 assistance with the preparation of the manuscript.
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