Assessing and Managing Delirium in Older Adults with Dementia

Best Practices in Nursing Care for Hospitalized Older Adults with dementia
from The John A. Hartford Institute for Geriatric Nursing and the Alzheimer’s Association Issue Number D8, Revised 2007

Series Editor: Marie Boltz, MSN, APRN, BC, GNP
Managing Editor: Sherry A. Greenberg, MSN, APRN, BC, GNP
New York University College of Nursing

WHY: Delirium in a patient with pre-existing dementia is a common problem that may have life-threatening complications, especially if unrecognized and untreated. Acute changes in mental status in older adults with dementia are often attributed to the underlying dementia or “sundowning.” Delirium is thought to occur 4-5 times more often in a person with dementia. Delirium superimposed on dementia is less likely to be recognized and treated than is delirium without dementia. In patients with dementia, delirium can substantially worsen long-term outcomes, including prolonged hospitalization, further decline in cognitive and physical functioning, re-hospitalization, nursing home placement, and death.^1-3 Delirium in older adults with dementia may be a sign of preventable and treatable medical problems or serious underlying illnesses such as a myocardial infarction, urinary tract infection, pneumonia, pain, or dehydration. Common medications causing delirium include diphenhydramine, benzodiazepines, anti-depressants, and anti-psychotics.⁴ An unrecognized delirium may interfere with recovery and rehabilitation after a hospitalization.²

BEST TOOLS: Delirium is difficult to assess in older adults with dementia and in hospitalized older adults due to overlapping features of delirium and dementia and the uncertainty of the patient’s baseline mental status. Most tools to assess delirium are less specific when assessing delirium in older adults with dementia. Use a standardized tool to measure delirium, if possible, such as the Confusion Assessment Method (CAM)⁵ (See Try This: Confusion Assessment Method). The CAM focuses on the KEY FEATURES OF DELIRIUM: Acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. The Delirium Superimposed on Dementia Algorithm suggested on page two recommends a process for assessing for delirium for people with a pre-existing dementia.

TARGET POPULATION: The Delirium Superimposed on Dementia Algorithm should be used with any older adult with dementia who is hospitalized, at home, in assisted living, in the nursing home, or in the emergency room with a change in mental or physical functioning. All older adults with dementia who experience an acute change in mental or physical functioning and/or behavior changes, should be assessed for delirium superimposed on the dementia.

STRENGTHS AND LIMITATIONS: While the CAM is a useful tool, the Delirium Superimposed on Dementia Algorithm recognizes that the patient’s baseline mental status is a critical parameter for assessing and treating delirium. It recommends review of the patient’s medical record for indications of pre-existing dementia, and checking with the patient’s family, if any, as to whether the patient has a diagnosis of dementia or signs and symptoms of possible dementia. If a patient is admitted from an assisted living or long term care facility, the nurse should question the staff at the facility about the patient’s baseline mental and functional status. The algorithm can be used with patients with dementia who present to the hospital without previous medical evaluation, and/or family members who cannot describe the patient’s mental status pre-hospitalization, who are at increased risk for undetected delirium. The algorithm helps address ageism, a significant barrier to detecting the presence of delirium, wherein clinicians attribute further cognitive loss or lethargy in a person with dementia as an inevitable fact of life for older adults. (See Try This: Recognition of Dementia in Hospitalized Older Adults).

FOLLOW-UP: The algorithm includes assessment of mental status and physical functioning on a daily basis. Communication amongst interdisciplinary team members across health care settings is crucial to the detection and treatment of delirium in older adults, especially during times of acuity and transition.

REFERENCES:

Best practice information on care of older adults: www.GeroNurseOnline.org.
1. Fick, D., Kolanowski, A., Waller, J., & Inouye, S.K. (2005). Delirium superimposed on dementia in a community-living managed care population: A three year retrospective study of prevalence, costs, and utilization. Journals of Gerontology: Medical Sciences, 60A(6), 748753.
2. Inouye, S.K. (2006) Delirium in older persons. NEJM, 354(11), 1157-65.
3. Fick, D.M., Agostini, J.V., & Inouye, S.K. (2002). Delirium superimposed on dementia: A systematic review. JAGS, 50(10), 1723–1732.
4. Han, L., McCusker, J., Cole, M., Abrahamowicz, M., Primeau, F., & Elie, M. (2001). Use of medications with anticholinergic effect predicts clinical severity of delirium symptoms in older medical inpatients. Archives of Internal Medicine, 161(8), 1099–1105.
5. Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A., & Horwitz, R. (1990). Clarifying confusion: The confusion assessment method. Annals of Internal Medicine, 113(12), 941-948.

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