Eliminate Noxious Agents Acting as Triggers
The authors deserve thanks for their profound exploration of this topic, which is so important in routine clinical practice (1). (Onsetting) dementia is a predisposing factor, and delirium is common in dementia (ICD F05.1). Often, undetected dementia is unmasked only by delirium. Identifying such patients in advance by using suitable screening instruments lowers the frequency of delirium drastically (2). It is important to mention that in patients with known dementia and plausible trigger factors, the diagnostic efforts should be kept in proportion: electroencephalogram and cerebrospinal fluid (CSF) analysis are not among the basic diagnostic tools.
With regard to treatment it should be emphasized that the elimination of noxious substances acting as triggers is the first priority; these include numerous medications—and especially polypharmacy. The importance of environmental therapeutic factors (alleviating patients’ fears/anxiety, enable reorientation) should not be underestimated, since a lack of orientation and fear/anxiety lead to further escalation of the pathophysiological cascade of delirium via corresponding psychophysiological mechanisms (3). Long acting benzodiazepines should not be used to treat delirium in elderly patients because of the risk of gradual intoxication, with adverse effects including respiratory depression.
Delirium usually does not last longer than hours to several days, but in some cases it may persists for weeks, including postoperatively. Durations of six months have been observed (4). The reversible character of the symptoms is then often overlooked and hospitals admit patients prematurely to nursing homes.
Dr. med. Dirk K. Wolter
Psykiatrien i Region Syddanmark
Gerontopsykiatrisk Afdeling Haderslev
|1.||Lorenzl S, Füsgen I, Noachtar S: Acute confusional states in the elderly—diagnosis and treatment. Dtsch Arztebl Int 2012; 109(21): 391–400. VOLLTEXT|
|2.||Gurlit S, Möllmann M: How to prevent perioperative delirium in the elderly? Z Gerontol Geriatr 2008; 41: 447–52. CrossRef MEDLINE|
|3.||Oesterreich K: Verwirrtheitszustände. In: v. Kisker KP, Lauter H, Meyer J-E Müller C, Strömgren E. Psychiatrie der Gegenwart. 3. Aufl., Bd. 8: Alterspsychiatrie. Berlin, Heidelberg: Springer Springer 1989; 201–24.|
|4.||Cole MG, Ciampi A, Belzile E, Zhong L: Persistent delirium in older hospital patients: a systematic review of frequency and prognosis. Age Ageing 2009; 38: 19–26. CrossRef MEDLINE|