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Delirium among older people in hospital often untreated

Acute confusion, which can triple the likelihood of death, is widespread among older people in hospitals and nursing homes but often goes untreated, according to new British and American research.

The condition - also known as delirium - is often undiagnosed, ignored or accepted as inevitable despite the fact it has an negative impact on people’s independence and mental processes, and significantly raises the risk of them developing dementia.

The research team, led by the Regenstrief Institute and Indiana University, reviewed 45 years of research covering almost 600 studies. The findings of the research, some of which was carried out at the University of East Anglia, is published in September’s issue of the Journal of Hospital Medicine.

With a third of delirium cases found to be preventable the researchers are calling for its early identification and treatment to improve people’s long-term prognosis.

The research showed more than 60% of delirium cases in general patient groups are not recognised or treated, with elderly patients leaving hospital in significant numbers with ongoing acute confusion that has been missed.

Among the measures that could prevent delirium were treating depression, getting rid of restraints, making sure patients have access to glasses and hearing aids and prescribing classes of antipsychotics that do not negatively affect the ageing brain, according to the research authors, who were led by Dr Babar Khan of the Regenstrief Institute and Indiana University School of Medicine.

A more sensitive screening tool for delirium, especially when used by a non-expert, were also needed, they said.

Readers' comments (23)

  • It might be helpful for the ordinary non-medical person who has an interest in some condition or other that effects the brain (in my case it is someone in my family who had/has hyponatraemia), to lay out more carefully what exactly is meant by delirium here. A dictionary definition gives:

    ...state of excitement and mental confusion, often accompanied by hallucinations, caused by high fever, poisoning, brain injury, etc.

    It would be helpful to have medical conditions that are the cause of it (including hypotraemia) and whether the source of delirium is significant. The simplest version of this is where once a condition is stabilised, how does the delirium ameliorate, what sorts of stages does it go through as it does, if it does, so that a clinician can see from the detailed changes he is observing, that for example, a patient had delirium, but things are improving. Not everyone presents with a set of the full blown symptoms.
    As you hint in your article, docs tend to find a quick label for something and move on. I is too time consuming to spend time observing a patient. In my experience of my relative's illness, they just popped in a few times to do a quick checklist to work out whether there was confusion, level of cognitive capacities, but delve further in order to have at hand the detailed knowledge of what a person is and is not capable of, so that on release from hospital, and transfer to, say, a care or nursing home, the staff there have something to work on, rather than just a few words like confusion resolved, or some such.Tendency for intermittency being one of the most helpful things to know. As is true for all types of dementia.

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  • I tried to have my say.
    You apparently do not want to hear it!

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  • Recent research!
    If we have not learned by now? It is basic common sense and does not require expensive studies/research as an excuse to ascertain:-
    When older/visually impaired people are admitted to hospital it would help them tremendous if someone could ensure (dare I sat it) put a little bit of physical effort into giving them fluids/diet (do not believe the written word on these charts) There are many witnesses to what actually happens!

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  • Basically a UTI can cause delirium in elderly people, symptoms, confusion, aggression etc...

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  • Anonymous | 20-Sep-2012 3:59 pm

    Basically a UTI can cause delirium in elderly people, symptoms, confusion, aggression etc...



    I think you will find nurses who have done a few years to qualify actually know this already. any infections and fever as well as dehydration can cause delirium. it has multiple causative factors.

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  • should have read above 'a few years study to qualify ...'

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  • I must add that all the bed moves exacerbate this - goodness knows how much??

    Also, we 'save' patients or 'so-called prevent' illness on one hand, only to finish them off in another way. A good government ploy, thinking they pull the wool over our eyes. Am I the only person thet thinks this way?

    ... from an almost 40 year NHS veteran

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  • Anonymous | 20-Sep-2012 4:08 pm

    "I think you will find nurses who have done a few years to qualify actually know this already. any infections and fever as well as dehydration can cause delirium. it has multiple causative factors."

    That was rude

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  • Anonymous | 21-Sep-2012 8:35 am

    Anonymous | 20-Sep-2012 4:08 pm

    "I think you will find nurses who have done a few years to qualify actually know this already. any infections and fever as well as dehydration can cause delirium. it has multiple causative factors."

    "That was rude" !!!!!!!

    there is noting rude in restating the facts but i find it offensive to qualified nurses to underestimate their knowledge, besides the causes of delirium, as I said, are multifactorial.

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  • I believe that all nurses should have training in Dementia awareness. I know it is all common sense but in the hospital environment where there are critically ill patients on the same wards it is imperative that the nurses have the support needed to assist these patients.

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  • Sandra Joyce Powell | 21-Sep-2012 9:44 am

    I totally agree with you. I am fortunate enough to have had such training and worked on a general medical ward but although my understanding of the condition and their needs has greatly increased I still found patients with dementia very hard to manage on a general ward.

    I consider a good background and understanding of all mental health disorders is also very important for generalists and I found I constantly had to draw on my knowledge in this area.

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  • From personal family experience there is a major issue here despite all of the theoretical knowledge. This knowledge is not put in to practice.

    How can someone with a severe UTI be diagnosed with Dementia with no attempt to treat the UTI? It happened and is still happening and can be life changing. Even if there is Dementia present, this does not exclude the possibility of an acute deterioration due to an infection or other cause but once a diagnosis of Dementia is made then there is very little hope of getting anything else taken seriously and treated unless the indivudual happens to have a great advocate who knows what they are talking about. I know, I had to go through this and what is particularly sad is that the GP was absolutely on side and trying to treat the UTI but the individual concerned was too confused to take the anti-biotics properly so was admitted to hospital due to further deterioration and risk to be treated at which point the hospital refused to treat for a UTI because a dip-stick didn't suggest an infection. The fact that a handful of anti-biotics had been taken and the clinical picture of acute confusion was still present indicating a clinical need more than just a dip-stick was ignored until I managed to convince the consultant to test. Guess what, it came back as a raging UTI!! Just imagine if I had not done this. It frightens me to death to think that one day this could be me. I have no confidence in it changing by then because this is not a new problem and as people above rightly say, we have known this for years and no amount of research or evidence is going to persuade me that this is new. What I need to be persuaded of, is that it is being applied.

    Sorry this is so long, but it makes me so cross that we still ignore this knowledge and so many older people suffer terribly as a result.

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  • tinkerbell

    Anonymous | 21-Sep-2012 3:17 pm

    well said and well done. So many toxic confusional states would have most of us diagnosed with 'dementia' and then left on the scrap heap.

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  • tinkerbell

    the first rule of psychiatry is 'to
    eliminate a physical cause'. I have nurse a few patients who were seriously, physically ill with life threatening illnesses, who have been sent to psyche wards only to find out upon further investigation they were dying of a physical illness. So sad that they had to take 'antidepressants' and 'antipsychotics' & tranquillisers in the meantime until this was properly established as it shoud have been in the first place.

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  • tinkerbell | 23-Sep-2012 2:53 pm

    sadly this must not be uncommon, especially among the elderly who it is assumed most will have dementia after a certain age. Also in GP practices, in A&E and on busy medical wards where corner cutting risks are taken in failing to establish correct differential diagnoses.

    It happened to the Mum of a friend of mine when she was hospitalised in a cottage hospital for a leg ulcer which had failed to heal. She was in her 80s or 90s and became confused within 24 hours of admission. When her daughter, who is not a nurse, but the mother was so she may have learned from her, visited the next day she found her more or less pushed into a corner and apparently neglected. on speaking to a nurse she was informed that her mother had dementia although there was no formal diagnosis of this, just personal judgement! The daughter discovered that since her admission she had become completely dried out!

    After the necessity of inserting a Venflon through her wafer thin skin into her fragile already collapsed veins, with the inherent risks and extra costs of this avoidable procedure, she quickly recovered to her usual alert and intelligent old self but why was such treatment made necessary and why dismiss her with a diagnosis of dementia without any relevant clinical observations from the medical and nursing staff or diagnostic tests being carried out?

    This is a potentially highly dangerous and totally unacceptable situation brought about by professional negligence through poor communications, lack of observations and basing clinical diagnosis merely on a set of false assumptions without out any clinical evidence or backing. That is not knowledgeable, skilled and experienced nursing which entry to the professional register requires.

    It also left a strong and lasting impression with my friend that nursing staff have become careless and simply do not care. Regardless of whether this is true or not this is the impression such treatment leaves with patients and relatives as the recipients of such care and service and can precipitate tragic and untimely death often dismissed as mental confusion and old age.

    Delirium is a very serious and highly dangerous condition associated with infection, fever and dehydration which with attention to the early warning signs can be preventable and is in any case usually treatable and reversible.

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  • tinkerbell

    Anonymous | 23-Sep-2012 3:35 pm

    this was when i worked with young adults, both patients had cancer, one was diagnosed with post natal depression and the other with acute anxiety. I asked the ward doctor to check the young woman diagnosed with post natal depression again and he did, although relectantly and for him to carry out another physical investigation, which he did. He then called the medics, she was transferred to another hospital and died shortly afterwards following brain surgery for a tumour.

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  • tinkerbell | 23-Sep-2012 4:49 pm

    Anonymous | 23-Sep-2012 3:35 pm

    just shows the vital role of good nursing

    we need to tell the world these stories so that the profession can get the support it needs to develop much further


    instead of all these studies and audits somebody should be doing research into the vital role of nurses and the consequences of their absence but as long as the health service continues to be money and politically driven for the benefit of a certain few rather than the nation and its patients it ain't goin' to happen!

    how often do we during the course of our daily work and our careers pick up things doctors have overlooked or errors they have made. not to criticise them but it is team work where checking and double checking is vital for patient safety and doctors and nurses of whatever level and experience need to work alongside each other.

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  • tinkerbell

    µ | 23-Sep-2012 5:43 pm

    exactly, the nurse is with the patient much more than the doctor.

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  • my problem is I have got so used to querying everything I do it when I am a patient as well without realising. after 30 odd years it has become a habit. doctors don't like that very much. the last GP I saw said I was very mistrustful!

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  • tinkerbell

    µ | 23-Sep-2012 6:29 pm

    occupational hazard of being a nurse.

    I was told that nurses make the worst patients. Personally i never mention i am a nurse unless asked, but on the ward we are the eyes and ears of the doctors and should be influential in assisting the doctor with their reviews of the patients well being or not and compliment one another as professionals.

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