What is Delirium?
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM) – IV, delirium is described by the following criteria1:
- Disturbance of consciousness with reduced ability to focus, sustain, or shift attention
- A change in cognition (memory, language, or orientation) or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia
- The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day
- There is evidence from the history, physical, or laboratory findings that the disturbance is caused by direct physiological consequences of a general medical condition
Delirium may be classified under three “sub-types”
Why is Delirium an important issue in hospitals?
- Delirium is common in older people admitted to hospital:
- 10-15% of older people admitted to acute care are delirious at the time of admission2
- 31% of older people admitted to ICU are delirious at the time of admission3
- Delirium occurs frequently in older people over the course of their hospital stay:
- 10-40% of older patients in acute care develop new episodes of delirium4
- 41-56% of patients 60 years and over develop delirium after hip fracture surgery5,6
- 15% of patients 60 years and over develop delirium after elective hip surgery5
- 32% of patients 65 years and over develop delirium after coronary artery bypass surgery7
- 31% develop delirium while in the intensive care unit2
- 83% develop delirium when mechanically ventilated8
- Delirium may persist for weeks or months, and is associated with negative outcomes:
- Increased mortality, post-operative complications, functional decline, and long-term cognitive impairment4,9,10
- Increased hospital length of stay and need for admission to long term care4,9,11
- Increased health care costs12
- Delirium is frequently overlooked or under-diagnosed due to limited staff knowledge about delirium13,14
- Delirium may be prevented by screening high-risk patients and by working together as an inter-professional team to implement multi-component interventions15
What are foreseeable outcomes when Delirium is appropriately addressed?
- For the patient
- Decreased number of episodes, duration, or severity of delirium
- Improved cognitive and physical function
- Improved rate of return to pre-hospital living environment
- For hospital staff
- Improved ability to detect and reduce delirium
- Improved inter-professional collaboration
- Empowerment and improved satisfaction when caring for older adults
- For the healthcare system
- Decreased morbidity and mortality
- Decreased institutionalization
- Decreased length of stay and ALC rates
- Decreased costs of health care16
- Improved patient and family satisfaction
What can be done across the organization to address Delirium?
1 American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington DC: American Psychiatric Association.
2 Britton A, and R Russell (2005). Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment. The Cochrane Database of Systematic Reviews. Article No: CD000395.pub2. DOI: 10.1002/14651848.CD00395.pub2.
3 McNicoll L, MA Pisani, Y Zhang, EW Ely, MD Siegel, and SK Inouye (2003). Delirium in the intensive care unit: Occurrence and clinical course in older patients. Journal of the American Geriatrics Society 51: 591-598.
4 Fann, JR (2000). The epidemiology of delirium: A review of studies and methodological issues. Seminars in Clinical Neuropsychiatry 5: 64-74.
5 Galanakis P, H Bickel, R Gradinger, S Von GUmppenberg, and H Forsti (2001). Acute confusional state in the elderly following hip surgery: incidence, risk factors, and complications. International Journal of Geriatric Psychiatry 16(4): 349-355.
6 Santana Santos F, LO Wahlund, F Varli, I Tadeu Velasco, and M Eriksdotter Jonhagen (2005). Incidence, clinical features and subtypes of delirium in elderly patients treated for hip fractures. Dementia and Geriatric Cognitive Disorders 20(4): 231-237.
7 Rolfson DB, JE McElhaney, K Rockwood, BA Finnegan, LM Entwistle, JF Wong, ME Suarez-Almazor (1999). Incidence and risk factors for delirium and other adverse outcomes in older adults after coronary artery bypass graft surgery. Canadian Journal of Cardiology 15(7): 771-776.
8 Ely, EW, SK Inouye, GR Bernard, S Gordon, J Francis, L May, B Truman, T Speroff, S Gautam, R Margolin, RP Hart, and R Dittus (2001). Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). Journal of the American Medical Association 286: 2703-2710.
9 Ely, EW, A Shintani, B Truman, T Speroff, SM Gordon, FE Harrell Jr, SK Inouye, GR Bernard, and RS Dittus (2004). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. Journal of the American Medical Association 291(14): 1753-1762.
10 McCusker, J, M Cole, N Dendukuri, E Belzile, and F Primeau (2001). Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study. Canadian Medical Association Journal 165: 575-583.
11 Pompei, P, M Foreman, MA Rudberg, SK Inouye, V Braund, and CK Cassel (1994). Delirium in hospitalized older persons: outcomes and predictors. Journal of the American Geriatrics Society 42: 809-815.
12 Inouye, SK (2006). Delirium in older persons. New England Journal of Medicine 354: 1157-1165.
13 Elie M, F Rousseau, M Cole, F Primeau, J McCusker, and F Bellavance (2000). Prevalence and detection of delirium in elderly emergency department patients. Canadian Medical Association Journal 163: 977-981.
14 Hustey FM, and SW Meldon (2002). The prevalence and documentation of impaired mental status in elderly emergency department patients. Annals of Emergency Medicine 39: 248-253.
15 Inouye SK, ST Bogardus Jr, DI Baker, L Leo-Summers, and LM Cooney Jr (2000). The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Journal of the American Geriatrics Society 48: 1679-1706.
16 Rizzo JA, ST Bogardus Jr, L Leo-Summers, CS Williams, D Acampora, and SK Inouye (2001). Multicomponent targeted intervention to prevent delirium in hospitalized older patients: what is the economic value? Medical Care 39(7): 740-752