Illness in the elderly is often manifested with a condition called delirium. This is an acute state of confusion presenting with drowsiness, loss of memory, fluctuating levels of consciousness and frequently hallucinations and delusions. Many individuals who are frail often do not present with the symptoms of a disease such as a urinary tract infection or pneumonia, but with delirium. 

While uncommon in the community, delirium occurs in anywhere from 14-34 percent of hospital patients, but amongst those over the age of 80, over 70 percent have symptoms of delirium, particularly if they are about to undergo major surgery or are being treated in the ICU.

Delirium is often the initial symptom of an acute medical illness such as a urinary tract infection, pneumonia, sore throats, bronchitis and influenza. Many medications can lead to delirium, as can major illnesses such as a heart attack, stroke or hip fracture. On occasion it may be situational — brought on by a change in environment such as moving to a new facility or being admitted to a hospital for an elective procedure.

There are many risk factors for delirium, but far and away the most common is dementia, caused by strokes, Parkinson’s disease and most commonly Alzheimer’s. Delirium is more frequent in those with sensory deficits such as hearing loss or blindness, immobilization because of catheterization and frequently by the use of restraints. For reasons that are ill understood, delirium is more common in males and those with chronic renal or liver disease. The greater the number of chronic medical conditions, the greater the risk of delirium.

Dehydration is frequently present in patients with delirium and is the most common underlying cause of an acute state of confusion in the elderly. Compared to young people, older persons have a markedly reduced thirst drive. When they become ill, water loss is increased. Frequently the fluid loss is not replaced, and this in turn leads to increasing confusion and continuing worsening of symptoms.

When hospitalized, patients with delirium frequently become more agitated, pull out intravenous lines and may remove urinary catheters kept in place by an expanded balloon. This leads to injury and even worse, agitation. Often patients are restrained and prescribed psychotropic medications that may cause some but insufficient improvement. The combination of restraints to prevent injury and medications to reduce agitation frequently cause more harm than good. Hospital stays are increased, complications are high, and death is frequent.

There is much that can be done to prevent and manage delirium in ways that minimize complications. The importance of assuring adequate fluid intake is critical if an older individual develops an illness or shows signs of confusion. The earlier a diagnosis is made and the medical condition appropriately treated the better. Admission to hospital must be avoided as much as possible. Sadly, many families wait too long after symptoms develop to consult their doctor. Even over the phone, the physician can often help identify and treat the problem. 

Hospitals are now more aware of the problems of delirium in sick older individuals. New guidelines have been developed to minimize the risk of confusion both before and after surgery. Appropriate anesthesia can do much as well. And today many hospitals have specialized delirium units. These often have four beds and are monitored continuously by one or more nurses. The goal is to avoid the use of restraints, assure hands on nursing care to reduce risks of removing tubes and minimizing drugs that can aggravate the problem. Wherever possible, family members are encouraged to spend as much time as possible at the bedside. A familiar face and voice can do much to help disorientation and reduce agitation.

Often patients remain confused throughout the hospital stay. For this reason, the patient is better off at home, provided the family has the resources to assure recovery. These days, the push to shorten hospital stays paradoxically leads to discharge too early that in turn increases complications and results in multiple readmission to hospital.

The solution to confusion in sick older patients is to assure a team of health care providers who participate in care prior and during an illness. Providing appropriate care after hospitalization can do much to improve chances of recovery and assure a better quality of life.

Dr. David Lipschitz is the director of the Dr. David Health and Wellness Center in Little Rock. To find out more about Dr. David Lipschitz, visit www.drdavidhealth.com

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