.Delirium in the elderly 'FRAGILE'

Dr. Alexander Grippa - Geriatrician ASP Messina

The condition of frailty in the elderly, often characterized by polipatologia, polypharmacy and high risk of disability is often associated with a clinical condition with high prevalence in the geriatric age, sadly under-diagnosed: The Delirium.

This is a form of acute confusional state that is characterized as a disturbance in acute onset with fluctuating course and usually of short duration (hours or days).



Can occur in three forms:

- Overactive: prevailing restlessness, psychomotor agitation, behavioral disturbances predominantly nocturnal hallucinations.

- Underactive: tendency to impaired alertness, stupor, impoverishment of language.

- Mixed with alternation of two forms.

It 's a disease frequently found in hospitals, since approximately 10% of older people develop a form of delirium at admission (prevalent delirium), among them 31% occurs in ICU. Moreover, in patients already suffering from disabilities or dementia, this percentage may reach 70% at admission.

.. The incidence of delirium is it still high surgical patients, so that up to 50% of elderly patients with hip fracture symptoms attributable to this condition.

Regarding the etiology of delirium can be recognized in the leading causes medications (especially those with anticholinergic activity such as certain antipsychotics, tricyclic antidepressants, benzodiazepines, digitalis), organic diseases (infections, urinary retention, acute cardiovascular diseases, cancers) . In some cases discontinuation of treatment to trigger the symptoms of confusion, such as alcohol and sedatives.

Finally, do not seem irrelevant psychological causes such as hospitalization, depression and sensory deprivation.

It 'has also been demonstrated as a condition predisposing biochemical both reduced brain glucose metabolism, this among other things, in case of dementia, other predisposing factors are represented by visual and auditory deficits and dehydration (indicated by a high ratio of creatinine / BUN).

Certain environmental conditions are instead the role of precipitating factors, such as the use of bladder catheter, the use of means of restraint, pressure sores, the institutionalization hospitalization (frequent cause of immobilization).

The correlation with dementia is controversial, on the other hand, the delirium may be a harbinger of dementia below.

... The importance of putting a correct diagnosis of delirium is very important when you consider that an average of 50% the disease is not diagnosed (symptoms are often confused with dementia, aging or depression) .



Therefore we must rifersi selective criteria such as those listed in the Confusion Assessment Method (CAM):

- Occurrence of acute symptoms and fluctuating course

- Disorganization of thought

- Altered level of consciousness

Delirium if there are the three criteria.



At the end of a good preventive action is needed on several fronts:

- Correction of visual and auditory deficits

- Prosthetic environment (good lighting, avoiding shadows and noises that can cause hallucinations, and foster socialization

- Reality Orientation Therapy (ROT) in patients with dementia;

- Careful monitoring of hydration status and oxygenation

- Emergency treatment of acute illness.

. The medication should be reserved only for cases particularly disturbing and dangerous, is preferred to use low doses of haloperidol, or atypical antipsychotics such as risperidone, the benzodiazepines are not recommended (except for cases of abstinence from alcohol).

Emerges from that described the severity of a clinical situation is often misunderstood, but potentially reversible disability.

A proper preventive approach based on Multidimensional Geriatric Assessment may shorten the onset.
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