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risk factors for delirium

Etiology: - advanced age (> 70 years) - elderly are sensitive to most medications - elderly frequently taking multiple medications - visual impairment** - hearing impairment, including cerumen impactation - vulnerable homeostasis mechanisms - pre-existing central nervous system disease - prior history of dementia, cognitive impairment** - history of stroke, epilepsy - diminished cerebral perfusion or hypoxia - uncontrolled pain - recent surgery - depth of anesthesia [4,5] - use or dependence on CNS depressants - alcohol (alcohol abuse within 1 month) - hypnotics - opiates - administration of psychoactive medications - drug overdose or illicit drug use within a week - severe illness (APACHE score > 16)** - infection - sleep deprivation, sleep disturbance (common in hospitalized patients) - transfer from a nursing home - prior history of depression - hypoxemia [3] - hypercarbia [3] - metabolic disorders & endocrine disorders - hyponatremia or hypernatremia - hypoglycemia or hyperglycemia - hypothyroidism or hyperthyroidism - hyperparathyroidism - Cushing's syndrome or adrenal insufficiency [3] - hypothermia or fever - BUN/Creatinine ratio > 18, dehydration** - organ failure - renal failure (creatinine > 2 mg/dL) - heart failure - live failure [3] - urinary retention (cystocerebral syndrome) - liver disease (bilirubin > 2 mg/dL) - history of congestive heart failure - volume overload - elevated systolic blood pressure - cardiogenic shock, septic shock - HIV infection - tube feeding - rectal or bladder catheters - central venous catheters - malnutrition - thiamine deficiency - vitamin B12 deficiency - niacin deficiency [3] - use of physical restraints - immobility - no clock or calender - frequent room changes - surgery or trauma, ICU setting [2] - lack of sleep, mechanical ventilation, severe pain - use of anxiolytics & analgesics - total parenteral nutrition - anemia - table 2 of ref [8] lists 33 predisposing factors associated with delirium - table 3 of ref [8] lists 112 precipitating factors associated with delirium ** one of 4 risk factors in predictive model for delirium in hospitalize elderly * also see drugs commonly producing delirium * prehospital statin therapy with continued statin therapy during hospitalization may diminish risk of delirium in critically ill elderly [6,7] Management: - dementia, age > 75 years, & functional impairment identify elderly at highest risk for delirium in the emergency department [9]

Related

drugs commonly producing delirium

Specific

precipitating factors associated with delirium predisposing factors associated with delirium

References

  1. Mahler ME, In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 29-Oct 2, 2004
  2. Lat I et al. The impact of delirium on clinical outcomes in mechanically ventilated surgical and trauma patients. Crit Care Med 2009 Jun; 37:1898 PMID: 19384221 http://dx.doi.org/10.1097/CCM.0b013e31819ffe38
  3. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17. American College of Physicians, Philadelphia 2009, 2012, 2015 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Sieber FE, Zakriya KJ, Gottschalk A et al Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair. Mayo Clin Proc. 2010 Jan;85(1):18-26. Erratum in: Mayo Clin Proc. 2010 Apr;85(4):400. Dosage error in article text. PMID: 20042557
  5. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  6. Morandi A, Hughes CG, Thompson JL et al Statins and delirium during critical illness: a multicenter, prospective cohort study. Crit Care Med. 2014 Aug;42(8):1899-909. PMID: 24810528 Free PMC Article
  7. Page VJ, Davis D, Zhao XB Statin use and risk of delirium in the critically ill. Am J Respir Crit Care Med. 2014 Mar 15;189(6):666-73. PMID: 24417431 Free PMC Article
  8. Ormseth CH, LaHue SC, Oldham MA et al Predisposing and Precipitating Factors Associated With Delirium. A Systematic Review. JAMA Netw Open. 2023;6(1):e2249950 PMID: 36607634 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2800112
  9. Seidenfeld J, Lee S, Ragsdale L et al. Risk factors and risk stratification approaches for delirium screening: A Geriatric Emergency Department Guidelines 2.0 systematic review. Acad Emerg Med. 2024 Jun 7. PMID: 38847070