Guess what I have been dealing with the last few days? Altered mental status in a parent. So I am digging in to learn more about dealing with it. And you get the benefit of catching the highlights.
Confusion in elderly can originate either from delirium, dementia, or a whole slew of other diagnoses. A marked recent change is usually a sign of delirium, but a thorough history and review of medications helps to differentiate.
The major physical causes of delirium that I found are:
1. Metabolic disorders, for example:
- Withdrawal from alcohol or sedative(s)
- Drug abuse
- Fluid & electrolyte imbalance
- Infections like UTI or pneumonia
- Damage from a stroke
- Heart failure
- Kidney failure
- Thyroid disorder
- Nutrition disorder
2. Infection like:
3. Medications such as:
- Anticholinergic agents
- Cardiovascular agents
- Narcotic and nonnarcotic analgesics
- OTC meds that can also cause delirium include:
- - Antihistamines
- - Anticholinergics
Physicians usually consider delirium as a flag waving at a potentially life-threatening problem. The good news is that delirium is transient, most often has a treatable medical cause.
What does delirium look like?
- Changes in cognition and consciousness are usually the first to be noticed
- Psychomotor and/or emotional abnormalities
- Orientation compromise
- Alertness may alternate dramatically with lethargy
- Alternating hyperactivity with hypoactivity
- Fearful, anxious, angry
- New onset of incontinence
- Memory deficits
- Change in sleep-wake cycle
- Altered perception and sensation
- Hallucinations, delusions, misperceptions
- Inability to perform math calculations
- Abnormal language substitution
- Misidentification of environment
- Impaired reasoning and judgment
- Labile moods – euphoria to depression
The greatest risk factor for delirium is advanced age. And a certain percentage of patients presenting with delirium actually die from the underlying cause.
Some tests and orders you might see:
- Full Neuro exam including cognitive and motor eval
- Neuropsych exam
- Bloodwork and urine test
- Head CT
- Head MRI
- CSF analysis
The goals of delirium treatment are to treat the underlying cause, adjust medications where needed, and promote patient safety.
Delirium often lasts about a week, and recovery can take several weeks with treatment.
A few ways to prevent or manage delirium in hospitalized patients:
- Careful initial assessment
- Early mobilization – eliminate barriers – ask for a PT consult to help prevent falls
- Early catheter removal
- Patient use of hearing aids and glasses
- Maximize oxygenation, hydration, and electrolyte balance
- Promote nutrition and bowel function
- Monitor labs and other test results
- Promote rest
- Encourage family visits – only two or three at a time
- Avoid restraints
- Discourage TV
- Use music, massage, and relaxation techniques
- Ask family to help with patient history, preferences, and to bring in something familiar from home
- Be sure family brings in POA or conservatorship papers early.
- Involve disciplines and family in EARLY discharge planning
The information is according to: American Family Physician and MedLinePlus , Journal of Neurology, Neurosurgery, and Psychiatry , The 2008 Summer Nursing Conference . The Mayo Clinic talks about how hyponatremia causes similar symptoms in the elderly.
The sandwich generation is in for quite a lot of work with parents who are living longer and requiring more and more care. So, for more information on this timely subject, try this: What Do You Do When Your Parents Live Forever?: A practical guide to caring for the elderly