Causes
The onset of delirium can be triggered by a person being physically unwell or when there has been a sudden change in medication. There are also some other factors that can increase the risk of experiencing delirium.
Possible causes
- Changes to prescribed drugs (and starting and stopping them).
- A change to the person’s environment such as a house move, a move into a nursing home or a move between hospital wards.
- Poor hearing or vision (including not having their glasses or hearing aid).
- Lack of oxygen or low blood pressure.
- Having an infection.
- Pain and anxiety.
- Constipation and, or problems passing urine.
- Dehydration and a lack of important vitamins and calories.
- Problems with the kidneys and liver.
Risk factors
Some people are more at risk of developing delirium than others:
- Older people taking multiple medications.
- People with dementia.
- People who are dehydrated or have a poor appetite.
- People with an infection (although low level infection may not show up on tests).
- People who are constipated or have urine retention.
- Older people.
- People who have had surgery, particularly hip surgery.
- People with sight and hearing difficulties.
- People who are nearing the end of their life.
- People who are in pain.
- People in an unfamiliar or distressing environment.
Examples
We have already identified that it can be difficult to spot delirium. The examples below are real life cases where the person has been experiencing delirium. Would you have thought of this?
Agitation: Rashid is a 75 year old gentleman who lives in a nursing home because he struggled with living alone. He is usually a fairly independent and outgoing person, he enjoys walking and likes to go out to the shops most days.
Over the past 3 days he has become more agitated and doesn’t want to eat or drink anything. This is not like him because he usually has a good appetite and is an avid tea drinker. He doesn’t have an obvious sign of illness like a fever.
He then started to think that one of the ladies in the nursing home was his wife who passed away some years before and who he loved dearly.
Confusion or acute psychiatric problem: Joyce is an 85 year old lady, a retired teacher who is still involved as a volunteer at her local primary school.
She underwent a planned gall bladder surgery and appeared to be making a good recovery. She was due to be discharged to her home in a few days but one evening she began to wander around the ward. Joyce began insisting that she be allowed to go home and then tried to drink washing up liquid.
Nurses found her vital signs and blood tests to be within normal range. The ward referral suggests she has an acute psychiatric problem.
Is Joyce more confused lately?
Do you think she has signs of delirium?
It turned out that Joyce was experiencing an episode of delirium because of the change in environment, not having her glasses with her and the stress of having the gall bladder surgery. It was caught early and by returning her glasses to her, adding familiar objects to her environment and providing additional support to her for a few weeks she began to feel better.
Withdrawn or depressed: Moreen is a 67 year old woman who enjoys taking care of her grandchildren, playing cards with a group of her friends and golf with her partner. She fell ill with a chest infection and was admitted to hospital. She was given antibiotics to treat the infection and this helped to improve her physical health.
She was also quite agitated and voiced concerns about her neighbours spying on her and plotting against her and her partner behind their back. This didn’t make sense to her partner because ordinarily they had a positive relationship with their neighbours. She was given Haloperidol to treat these symptoms.
However, she seemed to withdraw into herself and was no longer communicating with the staff or her partner. When she did it was to complain that she felt tired all the time and didn’t feel like doing the things she used to enjoy.
She was referred to a community team to get their opinion on whether Moreen should be treated for depression.
Is Moreen more confused lately?
Do you think she has signs of delirium?
It turned out that Moreen wasn’t communicating as she would usually because she had lost her hearing aids and couldn’t understand what was being said. She felt tired because of the new medication and this was inhibiting her from enjoying her usual hobbies. Once she got a new pair of hearing aids, the dose of Haloperidol was adjusted and she was back at home she started to make a recovery from her episode of delirium.
Delirium or psychiatric episode: Lydia is a 72 year old woman who has a long term diagnosis of bipolar disorder. She enjoys a variety of hobbies including playing piano, word puzzles and painting. She was admitted to hospital as her COPD symptoms had worsened significantly. She began to get very agitated and appeared to be disorientated. Her husband Tim was concerned and contacted Lydia’s usual psychiatrist, commenting “That’s not my wife!” as her behaviour was very unusual.
When her psychiatrist, whom she had known for many years, visited her on the ward she did not recognise him, or show any acknowledgement of their previous interactions. The ward doctor is of the opinion that all of these symptoms have a psychiatric rather than physical cause.
Is Lydia more confused lately?
Do you think she has signs of delirium?
It turned out that Lydia had a low level urinary tract infection and was in pain but she had not voiced this to the staff. This, on top of the exacerbation of her COPD, as well as being in an unfamiliar environment contributed to her experiencing an episode of delirium. Once the infection and her COPD were treated and she returned home she began to make significant improvements.
Summary
Someone who is caring for the person, perhaps a nurse, family member or carer can recognise the acute changes (within a matter of hours or days) in the person who is suffering from delirium.
Ask the question, “Is this person more confused lately?”
This question is known as the single question in delirium (SQiD).
Consider more:
- Are you surprised by any of the causes of delirium?
- Do you know anyone that falls into the risk factor categories?