NCLIP

Delirium in Older Adults

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Delirium in Older Adults

Key Points

  • Delirium is an acute, fluctuating disturbance in attention and cognition, often caused by medical illness or treatment effects.
  • Common reversible contributors include infection, dehydration, medication effects, withdrawal, pain, and sleep disruption.
  • Hypoactive delirium is frequently missed and is associated with poor outcomes.
  • Prevention and recovery rely on treating causes plus reorientation, hydration, sleep support, and family engagement.

Pathophysiology

Delirium results from acute brain dysfunction triggered by systemic stressors, neuroinflammation, medication burden, and metabolic instability. In older adults, reduced physiologic reserve and cognitive vulnerability lower the threshold for delirium onset.

It often presents as waxing and waning confusion and inattention. Delirium superimposed on dementia is common and requires comparison to baseline behavior to detect acute change.

Classification

  • Hyperactive delirium: Agitation, restlessness, emotional lability, possible hallucinations.
  • Hypoactive delirium: Lethargy, withdrawal, reduced interaction; often underrecognized.
  • Mixed delirium: Alternation between hyperactive and hypoactive patterns.

Nursing Assessment

NCLEX Focus

Acute inattention with fluctuating mental status in an older adult is delirium until proven otherwise.

  • Assess onset and fluctuation timeline relative to baseline cognition and function.
  • Assess reversible causes: infection, medication changes, dehydration, hypoxia, pain, constipation/urinary retention.
  • Assess high-risk comorbidities, polypharmacy exposure, and recent hospitalization/anesthesia.
  • Assess safety risks including falls, device removal, and inability to follow directions.
  • Assess caregiver observations because families often recognize early change first.

Nursing Interventions

  • Escalate medical evaluation promptly to identify and treat underlying causes.
  • Provide frequent reorientation cues, clocks/calendars, and familiar objects.
  • Optimize hydration, oxygenation, pain control, bowel/bladder comfort, and sleep hygiene.
  • Minimize deliriogenic medications when possible and monitor withdrawal risk.
  • Involve family/care partners to support reassurance, orientation, and continuity.

Diagnostic Delay

Missed hypoactive delirium can delay treatment and increase morbidity, length of stay, and institutionalization risk.

Pharmacology

Medication review is central because sedatives, anticholinergics, opioids, and interacting regimens can precipitate or worsen delirium. Nurses monitor necessity, dose burden, and response while prioritizing nonpharmacologic prevention and cause-directed treatment.

Clinical Judgment Application

Clinical Scenario

A hospitalized older adult with baseline mild dementia becomes newly inattentive, disorganized, and intermittently agitated after antibiotic and opioid changes.

Recognize Cues: Acute fluctuation and inattention indicate probable delirium superimposed on dementia. Analyze Cues: Infection, medication changes, and hospitalization stress are likely contributors. Prioritize Hypotheses: Immediate priorities are safety and urgent cause identification. Generate Solutions: Initiate delirium protocol with reorientation, hydration, and medication review. Take Action: Coordinate provider escalation and family-supported calming plan. Evaluate Outcomes: Improved attention, safer behavior, and return toward cognitive baseline.

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