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Delirium in geriatric patients - Coggle Diagram
Delirium in geriatric patients
What is Delirium?
Definition: An acute "organic brain syndrome" marked by sudden cognitive impairment and a clouded level of consciousness.
Key Feature: The severity of the symptoms characteristically fluctuates (changes) throughout the day.
Importance: It is common, life-threatening, and often under-recognized. It may be the only sign of a serious illness (like pneumonia) in older adults. Unlike dementia, delirium is an acute emergency but is reversible if the cause is treated early.
Risk Factors
Delirium occurs due to a complex interaction of two types of factors:
1. Potentially Modifiable Factors (Targets for Prevention)
Sensory: Hearing or vision loss.
Immobility: Being bed-bound, wheelchair-bound, or restrained (e.g., medical catheters).
Medications: Narcotics, sedative-hypnotics, anticholinergic drugs, corticosteroids, or polypharmacy.
Illness & Environment: Acute infections, dehydration, severe pain, surgery, sleep deprivation, or moving to an unfamiliar place (like the ICU).
2. Non-Modifiable Factors (High Risk - Require Close Monitoring)
Advancing age (>65 years) and male sex.
Pre-existing dementia or cognitive impairment.
History of stroke, neurological disease, falls, or chronic kidney/liver disease
The 3 Clinical Types
Agitated Type: The patient is highly irritable, shouts, fights, is disoriented, and may pull out lines or catheters.
Lethargic Type: The patient is calm, inactive, and excessively sleepy. Danger: This type is easily missed, placing the patient at high risk for unnoticed dehydration or starvation.
Mixed Type: The patient switches back and forth, acting lethargic during part of the day and agitated during another part.
Diagnosis: The CAM Method
To diagnose delirium using the Confusion Assessment Method (CAM), a patient must meet at least three criteria, where Criteria 1 and 2 are a absolute must:
Acute Onset & Fluctuating Course: Sudden change from baseline behavior that comes and goes.
Inattention: Difficulty focusing, being easily distracted, or losing track of conversations.
Altered Level of Consciousness: Any state other than standard "Alert" (e.g., hyper-alert, drowsy, or comatose).
Disorganized Thinking: Incoherent, rambling, or completely illogical flow of ideas.
Management Strategy
Non-Pharmacological Treatment (First Line)
Environment: Use a calm room with minimal light and noise stimuli. Avoid frequent room changes.
Orientation: Keep familiar objects/family members nearby, and use clocks and calendars to orient the patient.
Physical Care: Ensure proper hydration, treat infections, prevent constipation, and protect sleeping hours by spacing out medical interventions.
Avoid Hazards: Do not use physical restraints (they worsen agitation) and provide visual/hearing aids.
Pharmacological Treatment (When Necessary)
Haloperidol: The primary drug of choice for severe agitation 0.5-3.0 mg/day for a maximum of 3–5 days).
Risperidone: Widely used if the patient has underlying Alzheimer's disease.
Quetiapine: Recommended for delirium/hallucinations in patients with Parkinson's disease.
Benzodiazepines: Do not use them unless the delirium is explicitly caused by benzodiazepine withdrawal.
Address Hidden Pain: Always check for hidden, painful causes such as a full bladder (acute urine retention) or fecal impaction.