DELIRIUM

It is important to differentiate dementia from delirium, also referred to as acute confusional state. The demented older adult is far more likely to become delirious. The onset

of delirium in the demented individual may be mistaken as an exacerbation of the dementia and consequently not treated.^79,80

Delirium is an acute disorder developing over a period of hours to days and is seen frequently in hospitalized elderly patients. Prevalence rates range from 14% to 56% of hospitalized older adults and up to 90% of older adults ad­mitted to psychiatric hospitals. Delirium is defined by the DSM-IVR as an organic mental syndrome featuring a global cognitive impairment, disturbances of attention, reduced level of consciousness, increased or decreased psychomotor activity, and a disorganized sleep-wake cycle. The severity of the symptoms tends to fluctuate unpredictably but often is more pronounced at night.⁵⁷

Delirium can be a presenting feature of a physical ill­ness and may be seen with disorders such as myocardial infarction, pneumonia and other infections, cancer, and hypothyroidism. Patients with drug toxicities may present with delirium. Malnutrition, use of physical restraints, and iatrogenic events also can precipitate delirium.

The exact reason that delirium occurs is unclear. It is speculated that the decreased central nervous system capacity in older adults may precipitate delirium. Other possible contributing factors include vision and hearing im­pairments, psychological stress, and diseases of other organ systems. Delirium has a high mortality rate, ranging between 20% and 40%. Agitation, disorientation, and fearfulness— the key symptoms of delirium—place the individual at high risk for injuries such as a fracture from a fall.^79,80

Diagnosis of delirium involves recognition of the syn­drome and identification of its causes. Management in­volves treatment of the underlying disease condition and symptomatic relief through supportive therapy, including good nutrition and hydration, rest, comfort measures, and emotional support. Prevention of delirium is the overall goal; avoidance of the devastating and life-threatening acute confusional state is the key to successful manage­ment and treatment.⁸¹

In summary, health care for older adults requires unique considerations, taking into account age-related physiologic changes and specific disease states common in this population. Although aging is not synonymous with disease, the aging process does lend itself to an increased incidence of illness. The overall goal is to assist the older adult in maximizing indepen­dence and functional capabilities and minimizing disabilities that can result from various acute and chronic illnesses.

The evaluation of the older adult's functional abilities is a key component in gerontologic health care. Medical diagnoses alone are incomplete without an assessment of function. When evaluating levels of function, determination of the older adult's ability to perform ADL and IADL should be included.

Among the functional disorders that are common in the older population are urinary incontinence, instability and falls, sensory impairment, depression, dementia, and delirium. The older adult is especially prone to urinary incontinence because of changes in the micturition cycle that accompany the aging process. Behavioral techniques can be an effective way to treat incontinence problems in the older adult population. Falls

are a common source of concern for the older adult popula­tion. Although most falls do not result in serious injury, the po­tential for serious complications and even death is real. Most falls are the result of several risk factors, including age-related biopsychosocial changes, chronic illness, and situational and environmental hazards. Both hearing and visual impairment, which are common in elderly persons, contribute to commu­nication problems, depression, and social isolation. Depres­sion is a significant but treatable health problem that often is misdiagnosed and mistreated in the older adult population. Dementia is a syndrome of acquired, persistent impairment in several domains of intellectual function, including memory, language, visuospatial ability, and cognition (i.e., abstraction, calculation, judgment, and problem solving). Although there can be a slight decline in intellectual function with aging, de­mentia is not a normal aging process. Delirium is an acute con-fusional disorder developing over a period of hours to days and often is seen as a presenting feature of a physical illness or drug toxicity.