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General Principles in Older Adults

Confusion is a common presenting problem in many older patients, but it is not a normal part of aging. Most adults experience some cognitive changes as they age, such as decreases in the speed of processing information, lessened spontaneous recall, and small decreases in executive skills. Confusion, however, is not normal aging. When an older patient presents with confusion, it is important to determine whether the confusion is acute or chronic in nature. For example, is it a recent change (days to weeks) or has the change been more chronic and progressive in nature (months to years)? Sometimes the change will be manifested as an acute or sudden change in behavior, such as increased agitation, aggression, wandering, or falls, or a change in function. Understanding the nature and time line of the events will give you an indication regarding the potential underlying diagnosis.

Knowledge of baseline cognitive and physical functional status are key assessment parameters when evaluating confusion. Gathering baseline cognitive and functional status information from patients as well as caregivers, family, and friends will help you determine if the patient’s confusion represents an acute change as a result of delirium or if the confusion is more chronic and insidious, such as that related to dementia. It is important to note that while confusion is most commonly a symptom of delirium or dementia, it can also be associated with psychoses and affective disorders, specifically major depression.

Differential Diagnoses

Delirium

Delirium, often presenting as acute confusion, is a highly prevalent, preventable, life-threatening clinical syndrome in acutely ill older adults. It is characterized by an acute change in cognition and attention, with disturbances in consciousness, orientation, memory, thought, perception and/or behavior. In contrast to dementia, which is a chronic confusional state, delirium typically develops over a short period of time (hours to days), fluctuates over the course of the day (often worsening at night) with varying inability to concentrate, maintain attention, and sustain purposeful behavior. Anxiety, irritability, and psychomotor restlessness with insomnia are common. These patients may pick at their intravenous lines, take off their oxygen, disconnect monitoring equipment, exhibit poor safety awareness, and/or talk to people who are not present. Other perceptual disturbances (often visual hallucinations) are also commonly accompanied by paranoid delusional thinking exacerbating the patient’s behavioral and emotional manifestations. Agitated behaviors commonly associated with delirium often lead to use of physical and chemical restraints, further compounding the risk of functional loss and serious complications.

Family and caregivers may report the patient was “fine” during the day, but became confused, restless, and agitated during the middle of the night. The change, however, may be even more subtle: “She isn’t acting quite right.” When family and caregivers can pinpoint such a subtle change over the course of a day or week, that should be taken seriously, and delirium should be ruled out. ...

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