Abstract
Delirium is an acute neuropsychiatric syndrome and one of the most common presenting symptoms of acute medical illnesses in older people. Delirium can be triggered by a single cause, but in most cases, it is multifactorial as it depends on the interaction between predisposing and precipitating factors. Delirium is highly prevalent in older patients across various settings of care and correlates with an increased risk of adverse clinical outcomes. Several pathophysiological mechanisms may contribute to its onset, including neurotransmitter imbalance, neuroinflammation, altered brain metabolism, and impaired neuronal network connectivity. Several screening and diagnostic tools for delirium exist, but they are unfortunately underutilized. Additionally, the diagnosis of delirium superimposed on dementia poses a formidable challenge – especially if dementia is severe. Non-pharmacological approaches for the prevention and multidomain interventions for the treatment of delirium are recommended, given that there is currently no robust evidence of drugs that can prevent or resolve delirium. This article aims to review the current understanding about delirium in older people. To achieve this goal, we will describe the epidemiology and outcomes of the syndrome, the pathophysiological mechanisms that are supposed to be involved, the most commonly used tools for screening and diagnosis, and prevention strategies and treatments recommended. This review is intended as a brief guide for clinicians in hospital wards to improve their knowledge and practice. At the end of the article, we propose an approach to improve the quality of care provided to older patients throughout a systematic detection of delirium.
Highlights
Several years ago, Lipowski wrote: “Acute medical confusion as a presenting symptom holds a central position in the medicine of old age [. . .] acute confusion is a far more common herald of the onset of physical illness in an older person, than are, for example, fever, pain or tachycardia
Delirium prevalence was 23%, with variations related to diagnostic criteria used, a proportion which was similar to a systematic review performed 14 years earlier (Siddiqi et al, 2006)
The results of this study suggest that 4AT may be proposed as a tool to improve detection of delirium as well as Confusion Assessment Methods (CAM), or that either tool may have a role in screening depending on the setting and purpose
Summary
Lipowski wrote: “Acute medical confusion as a presenting symptom holds a central position in the medicine of old age [. . .] acute confusion is a far more common herald of the onset of physical illness in an older person, than are, for example, fever, pain or tachycardia. Lipowski wrote: “Acute medical confusion as a presenting symptom holds a central position in the medicine of old age [. . .] acute confusion is a far more common herald of the onset of physical illness in an older person, than are, for example, fever, pain or tachycardia. The elderly, especially the very old, are uniquely prone to delirium as a consequence of almost any physical illness or of intoxication with even therapeutic doses of commonly used drugs [. . .] Failure to diagnose delirium and to identify and treat its underlying causes may have lethal consequences for the patient, since it may constitute the most prominent presenting feature of myocardial infarction, pneumonia, or some other life-threatening physical illness” (Lipowski, 1983, 1989) The elderly, especially the very old, are uniquely prone to delirium as a consequence of almost any physical illness or of intoxication with even therapeutic doses of commonly used drugs [. . .] Failure to diagnose delirium and to identify and treat its underlying causes may have lethal consequences for the patient, since it may constitute the most prominent presenting feature of myocardial infarction, pneumonia, or some other life-threatening physical illness” (Lipowski, 1983, 1989)
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