Clinical Focus

Differentiation of delirium, dementia and delirium superimposed on dementia in the older person

Abstract

Delirium is an acute clinical emergency that requires prompt clinical intervention. A predisposing factor for delirium is dementia, and delirium may highlight the vulnerability of a patient to developing dementia. However, delirium also occurs during an acute illness in patients diagnosed with dementia; this is classified as delirium superimposed on dementia. This complex interplay of both dementia syndromes and the condition of delirium has been extensively studied. However, delirium continues to be under-recognised in the acute setting, which impacts negatively on patient outcomes. Nurses are the health professionals best placed to recognise a change in a patient's cognitive symptoms, but nurses caring for the older person have suggested the identification of and differentiation between delirium, dementia and delirium superimposed on dementia remains very confusing. A need for further education with supportive guidelines and protocols is required to empower nurses caring for an older person to verbalise changes in patients' cognitive status in a reliable, robust and systematic manner.

References

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edn. Washington DC: American Psychiatric Association; 1994 Google Scholar
Avelino-Silva TJ, Campora F, Curiati JAE, Jacob-Filho W. Association between delirium superimposed on dementia and mortality in hospitalized older adults: A prospective cohort study. PLoS Med. 2017; 14(3):e1002264. https://doi.org/https://doi.org/10.1371/journal.pmed.1002264 Crossref, Medline, Google Scholar
Bellelli G, Frisoni GB, Turco R, Lucchi E, Magnifico F, Trabucchi M. Delirium superimposed on dementia predicts 12 month survival in elderly patients discharged from a postacute rehabilitation facility. J Gerontol A Biol Sci Med Sci. 2007; 62(11):1306–1309. https://doi.org/https://doi.org/10.1093/gerona/62.11.1306 Crossref, Medline, Google Scholar
Bellelli G, Morandi A, Davis DHJ et al.. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing. 2014; 43(4):496–502. https://doi.org/https://doi.org/10.1093/ageing/afu021 Crossref, Medline, Google Scholar
Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006; 3(2): 77–101. Crossref, Google Scholar
Brooke J, Manneh C. Caring for a patient with delirium in an acute hospital: the lived experience of cardiology, elderly care, renal, and respiratory nurses. Int J Nurs Pract. 2018; e12643 (Epub ahead of print). https://doi.org/https://doi.org/10.1111/ijn.12643 Crossref, Google Scholar
Bush SH, Marchington KL, Agar M, Davis DHJ, Sikora L, Tsang TWY. Quality of clinical practice guidelines in delirium: a systematic appraisal. BMJ Open. 2017; 7(3):e013809. https://doi.org/https://doi.org/10.1136/bmjopen-2016-013809 Crossref, Medline, Google Scholar
Caplan JP, Rabinowitz T. An approach to the patient with cognitive impairment: delirium and dementia. Med Clin North Am. 2010; 94(6):1103–1116, ix. https://doi.org/https://doi.org/10.1016/j.mcna.2010.08.004 Crossref, Medline, Google Scholar
Cerejeira J, Mukaetova-Ladinska EB. A clinical update on delirium: from early recognition to effective management. Nurs Res Pract. 2011; 2011:1–12. https://doi.org/https://doi.org/10.1155/2011/875196 Crossref, Google Scholar
Day J, Higgins I, Koch T. The process of practice redesign in delirium care for hospitalised older people: A participatory action research study. Int J Nurs Stud. 2009; 46(1):13–22. https://doi.org/https://doi.org/10.1016/j.ijnurstu.2008.08.013 Crossref, Medline, Google Scholar
De J, Wand AP, Semerdely PI, Hunt GE. Validating the 4As test in screening for delirium in a culturally diverse geriatric inpatient population. Int J Geriatr Psychiatry. 2017; 32(12):1322-1329. https://doi.org/https://doi.org/10.1002/gps.4615 Crossref, Medline, Google Scholar
El Hussein M, Hirst S, Salyers V. Factors that contribute to underrecognition of delirium by registered nurses in acute care settings: a scoping review of the literature to explain this phenomenon. J Clin Nurs. 2015; 24(7-8):906–915. https://doi.org/https://doi.org/10.1111/jocn.12693 Crossref, Medline, Google Scholar
Fick DM, Hodo DM, Lawrence F, Inouye SK. Recognizing delirium superimposed on dementia: assessing nurses knowledge using case vignettes. J Gerontol Nurs. 2007; 33(2):40–47 Medline, Google Scholar
Fick DM, Steis MR, Waller JL, Inouye SK. Delirium superimposed on dementia is associated with prolonged length of stay and poor outcomes in hospitalized older adults. J Hosp Med. 2013; 8(9):500–505. https://doi.org/https://doi.org/10.1002/jhm.2077 Crossref, Medline, Google Scholar
Flanagan NM, Fick DM. Delirium superimposed on dementia. Assessment and intervention. J Gerontol Nurs. 2010; 36(11):19–23. Medline, Google Scholar
Fleet J, Ernst T. The prevention, recognition and management of delirium in adult in-patients. Clinical guideline. Guys and St Thomas' NHS Foundation Trust. 2011. http://tinyurl.com/ycgth2bx (accessed 27 March 2018) Google Scholar
Holroyd-Leduc JM, Abelseth GA, Khandwala F, et al.. A pragmatic study exploring the prevention of delirium among older hip fracture patients: applying evidence to routine clinical practice using decision support. Implement Sci. 2010; 5:81–86. https://doi.org/https://doi.org/10.1186/1748-5908-5-81 Crossref, Medline, Google Scholar
Huang J. Overview of dementia and delirium. MSD Manual. 2016. http://tinyurl.com/ybkovqlz (accessed 27 March 2018) Google Scholar
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990; 113(12):941–948. https://doi.org/https://doi.org/10.7326/0003-4819-113-12-941 Crossref, Medline, Google Scholar
Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014; 383(9920):911–922. https://doi.org/https://doi.org/10.1016/S0140-6736(13)60688-1 Crossref, Medline, Google Scholar
Jones RN, Manly J, Glymour MM, Rentz DM, Jefferson AL, Stern Y. Conceptual and measurement challenges in research on cognitive reserve. J Int Neuropsychol Soc. 2011; 17(04):593–601. https://doi.org/https://doi.org/10.1017/S1355617710001748 Crossref, Medline, Google Scholar
Kiely DK, Jones RN, Bergmann MA, Murphy KM, Orav EJ, Marcantonio ER. Association between delirium resolution and functional recovery among newly admitted postacute facility patients. J Gerontol A Biol Sci Med Sci. 2006; 61(2):204–208. https://doi.org/https://doi.org/10.1093/gerona/61.2.204 Crossref, Medline, Google Scholar
McAvay GJ, Van Ness PH, Bogardus ST Jr et al.. Older adults discharged from the hospital with delirium: 1-year outcomes. J Am Geriatr Soc. 2006; 54(8):1245–1250. https://doi.org/https://doi.org/10.1111/j.1532-5415.2006.00815.x Crossref, Medline, Google Scholar
Morandi A, Lucchi E, Turco R et al.. Delirium superimposed on dementia: A quantitative and qualitative evaluation of patient experience. J Psychosom Res. 2015; 79(4):281–287. https://doi.org/https://doi.org/10.1016/j.jpsychores.2015.07.010 Crossref, Medline, Google Scholar
National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. Clinical guideline 103. 2010. http://tinyurl.com/y93myfgl (accessed 27 March 2018) Google Scholar
Pun BT, Boehm L. Delirium in the intensive care unit: assessment and management. AACN Adv Crit Care. 2011; 22(3):225–237. https://doi.org/https://doi.org/10.1097/NCI.0b013e318220c173 Crossref, Medline, Google Scholar
Travers C, Byrne G, Pachana N, Klein K, Gray L. Prospective observational study of dementia and delirium in the acute hospital setting. Intern Med J. 2013; 43(3):262–269. https://doi.org/https://doi.org/10.1111/j.1445-5994.2012.02962.x Crossref, Medline, Google Scholar
van de Steeg L, IJkema R, Wagner C, Langelaan M. The effect of an e-learning course on nursing staffs knowledge of delirium: a before-and-after study. BMC Med Educ. 2015; 15(1):12. https://doi.org/https://doi.org/10.1186/s12909-015-0289-2 Crossref, Medline, Google Scholar
Wand APF, Thoo W, Sciuriaga H, Ting V, Baker J, Hunt GE. A multifaceted educational intervention to prevent delirium in older inpatients: A before and after study. Int J Nurs Stud. 2014;51(7):974–982. https://doi.org/https://doi.org/10.1016/j.ijnurstu.2013.11.005 Crossref, Medline, Google Scholar

12 April 2018Volume 27Issue 7

ISSN (print): 0966-0461
ISSN (online): 2052-2819

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History

Accepted 1 March 2018

Published online 10 April 2018

Published in print 12 April 2018

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