Martin M. Forsberg. Delirium Update for Postacute Care and Long-Term Care Settings: A Narrative Review. J Am Osteopath Assoc 2017;117(1):32–38. doi: 10.7556/jaoa.2017.005.
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Advances have been made in our understanding of the neuropathogenesis, recognition, and strategies for reducing the incidence of delirium in acute-care settings. However, relatively little attention has been given to delirium in elderly patients in the postacute care (PAC) and long-term care (LTC) settings. The present article reviews the most relevant current research pertaining to this population. Hospital patients with delirium are often discharged to PAC settings. Delirium that develops in the LTC setting is often more insidious and subtle in presentation. Despite incorporating systematic screening tools for delirium in PAC and LTC settings, delirium prevention strategies have not yet been shown to be beneficial beyond the acute-care setting. The management of delirium combined with dementia and guidance on when it is appropriate to use antipsychotic medications is also discussed.
Keywords: delirium, dementia, elderly, long-term care, postacute care
Delirium is a syndrome of altered mental status with prominent deficits in attention and a characteristic fluctuating course.
In all health care settings, especially in postacute care and long-term care, delirium is a cause of morbidity and mortality.
Although delirium often has a medical cause, symptoms can persist even after the medical condition has been resolved.
Delirium occurs in nearly 18% of long-term care patients who develop an acute illness and occurs more frequently in women.
Risk factors for delirium in long-term care include dementia, polypharmacy, restraint use, multiple illnesses, frailty, advanced age, and alcohol use.
New-onset perceptual disturbance, disorganized thinking, and worsening 3-object registration test results each predict delirium independently; patients with changes in all 3 symptoms were 3 times more likely to have delirium.
Unless delirium detection occurs early, the chance of a complete recovery is low. Delirium detection should ideally occur early and be communicated at the transition of care.
Instruments used to identify delirium include Confusion Assessment Method and Delirium Rating Scale Revised-98.
Infection is the most common cause of delirium in elderly patients.
Low-dose antipsychotic medication is commonly used in patients with delirium.
Although acute delirium should be seen as a medical emergency, the potential risks of transporting patients with delirium to the emergency department where their baseline is not known should be considered.
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