Aging & Health A to Z
Unique to Older Adults
This section provides information to help older adults and their caregivers consider their disease or condition in conjunction with other health issues.
As older adults live longer, they may have more than one chronic disease. Or, they may have a health problem that can lead to another condition or injury if not properly managed. The older adult may also experience healthcare in various settings, such as the hospital, assisted living facility or at home. These situations can affect the health and function of the older adult and therefore require careful management to ensure proper care and improve or maintain quality of life.
Delirium is a common occurence that can affect the health and quality of ilfe for older persons. Delirium often occurs with other diseases, such as dementia, stroke, Parkinson's disease, or depression.
Alzheimer’s Disease and Other Types of Dementia
Many older people develop a condition of slowly progressive cognitive or mental decline called dementia. Some of the causes of dementia in older people include:
- Alzheimer’s disease
- Vascular dementia
- Lewy body dementia
- Multi-infarct dementia (many tiny strokes, also called transient ischemic attacks or TIAs)
- Parkinson’s disease
Differences between delirium and dementia
People with dementia have a high risk of developing delirium. Symptoms of delirium can overlap with symptoms of dementia, with the result that healthcare workers may not recognize that a patient with dementia has developed delirium.
Any sudden change in behavior or mental functioning may be delirium. Although it is difficult to tell between delirium and dementia, it is important for your healthcare professional to do so because delirium can be reversible of treated right away. Three fo the key signs that a person is delirious are:
- You cannot get their attention
- Immediate changes in behavior, personality or temperment
- A change in level of consciousness (for example, super alert or drowsy)
If you suspect that someone in your care with Alzheimer’s disease has become delirious, you must alert a healthcare professional. Delirium may be caused by many things. One of the most common causes of delirium is medications, especially a reaction to a new medication. Among the most common medications that cause delirium are narcotics, benzodiazepines, anti-cholinergic medications, anti-Parkinsonian drugs, and some anti-epileptic medications. Acute infection, surgery, or a new illness are other common causes.
Stroke or Vascular Dementia
Sometimes people who suffer strokes develop delirium. This can occur without any other medical complications and regardless of whether the stroke was caused by a blood clot or a hemorrhage.
Delirium in Parkinson’s disease, Lewy Body and other Parkinson’s Dementias
People with Parkinson's disease are at high risk for developing delirium. Some drugs taken to control Parkinson’s disease may also bring on delirium in some patients.
Lewy body dementia is named after the abnormal Lewy body structures that appear in the brains of people suffering from this disease. Lewy body dementia produces symptom of dementia, signs of parkinsonism, and psychiatric disturbances, such as hallucination and behavioral troubles. In addition, patients with this problem will often develop delirium without apparent underlying cause.
Delirium and depression both happen more often than they are noticed in older people, sometimes at the same time. Depression can be triggered by many of the same medical problems that can cause delirium, such as heart disease, cancer, chronic lung disease, stroke, Parkinson’s disease, or dementia.
It is important to tell whether someone has depression, delirium or both, because the treatments are different for each one. A good clue that someone may be suffering from delirium and not depression is if the low mood or energy symptoms appear quickly. Depression tends to come on more slowly and persist for a long time unless it is treated. Patients who are depressed are also more likely to report that their memory is getting worse, while people with delirium or dementia may not notice or believe they are having memory problems.
Older persons who have both depression and delirium have more problems with their judgment because they are both suffering and confused. This means that they may be more likely to act on a suicidal thought, and should not be left alone if at all possible.
Some Important Causes of Delirium
Urine Retention or Fecal Impaction
Among the many reversible causes of delirium, urine retention and fecal impaction are much more common in older people. Both of these conditions cause discomfort, but if the patient is delirious, he or she will not be able to explain the situation.
If you are caring for an older person, make sure to monitor frequency of urination and bowel movements. Usually, urine retention can be treated with repeated bladder catherization or temporary insertion of an urinary catheter (not recommended for longer than 48 hours). Fecal impaction can be helped by enemas, mild laxatives, and subsequent stool softeners. Careful attention to diet and exercise afterward will help to prevent an impaction from recurring.
History of Alcohol or Substance Abuse
Delirium may be a symptom of alcohol or drug (e.g. benzodiazepine, opioid for sleep or pain) withdrawal if someone who is dependent on it stops consuming it suddenly. Delirium may also occur when taking illegal drugs like cocaine, LSD, PCP, or amphetamines, or as an adverse effect of particular medications. The healthcare professional treating the patient must be told exactly which drug the delirious patient has taken to make sure that treatment is appropriate.
Some of the symptoms of delirium that are possible during severe alcohol withdrawal or substance abuse include:
- Shaking and trembling (tremors)
- Changed mental functions like delirium, agitation, excitement, irritability, confusion, restlessness
- Shorter attention span
- Deep sleep lasting a full day or longer; general sleepiness, fatigue
- Sudden mood changes, including anxiety, depression, nervousness
- Extra sensitivity to light, sound, touch
- Seizures (epileptic-type fits)
- Loss of appetite or nausea and vomiting
- Heavy sweating
- Heart palpitations (fast, sometimes uneven heartbeat).
Delirium and Functional Impairment
If an independent older patient is suddenly—over a period of hours—unable to cope with the everyday functions of daily life, you should suspect that he or she may be suffering from delirium.
When a patient who has recently had surgery becomes delirious, his or her chances of recovering full function in their daily life are slowed or diminished compared to those who do not have delirium. About 40% of older surgical patients develop delirium after surgery.
Because delirium occurs so often after surgery in older patients, and since it raises the risk of poor functioning afterwards, it is extremely important to prevent and correct, and treat the factors that have brought it on.
Infections or Sepsis: Respiratory, Urinary, Skin
Sometimes, a bacterial infection can cause delirium. The infections that are most often linked to delirium include urinary tract infections (in bladder or kidneys), lung infections (pneumonia) or skin infections (from skin ulcers or drug-resistent bacteria). When bacteria (germs) invade your bloodstream, this is a condition called sepsis. Sepsis may sometimes occur after an operation, or it may develop from an infection in another part of your body.
Delirium may also result from a fever caused by a bacterial or a viral infection such as West Nile virus. Delirium is a strong indicator that a person is seriously ill, and symptoms may be present even before the infection has been discovered.
Some medicines commonly used in older adults can cause delirium in susceptible people. You must be particularly careful in the case of recently-started drugs taken to control depression, anxiety, or other mood or mental disorders. Even over-the-counter drugs that you can buy without a prescription, like antihistamines, sleep medicines, and anti-ulcer medications can lead to delirium.
Drugs that are known to cause delirium in some people include:
- anticholinergic drugs (available in many over-the-counter allergy and cold remedies, and sleeping medications)
- some antidepressants (such as tricyclic antidepressants)
- anti-epileptic medicines and barbiturates
- sedatives and hypnotics like benzodiazepines (i.e., Valium)
- sleep medications
- pain relievers containing narcotic drugs
- some allergy medicines, such as Benadryl
- some anti-Parkinson’s medicines
- digestive remedies such as H2 receptor blockers, anti-spasmodics, and anti-nausea drugs
- antibiotics in the fluoroquinolone class (such as Cipro or Levaquin)
- heart medicines such as digitalis or beta blockers.
While these medicines may be prescribed by your healthcare provider, you should discuss any concerns you may have. When prescribed, you should take the lowest effective doses available. Do not take over-the-counter medicines without talking to your healthcare provider.
Hospitalization or Environmental Change
Delirium is extremely common in older adults who have become hospitalized. Delirium is a well-known adverse effect of surgery, and is often evident in patients in the intensive care unit, or in long-term care institutions. As a person’s cognitive awareness begins to decline they may be prone to experiencing delirium if hospitalized. The absence of a familiar environment, recognizable family members, or even the frequent room changes that often occur in hospitals all increase the disorientation that may lead to an episode of delirium.
To decrease the risk and chances of delirium, try to make sure the person you are caring for has:
- eyeglasses and hearing aids if these are normally used
- a clock or watch in easy view
- the name of the doctors and nurses written clearly in sight
- plenty of light during the day (preferably a window with natural light)
- quiet and subdued light or darkness at night
- a family member or friend present whenever possible.
Delirium occurs most often in hospital post-anesthesia recovery units where patients are placed after general surgery. Pain management is of particular concern in these situations and it is importance that the patient communicates with their doctors if they experience pain. Unrelieved pain itself may bring on delirium. If the older person has difficulty hearing, this may make it harder to inform caregivers of the severity and degree of pain the patient is in. Hearing aids should always be worn (if possible) to establish clear communication while in the hospital.
Falls and Fractures
Delirium itself may cause a fall. This is due to the confusion, excitability, inattention, and misunderstanding of environmental cues that occur when a person experiences delirium. When you get older, your risk of a fall increases. There are many reasons for the increased risk—including balance problems, weak muscles, lack of exercise, general frailty, sudden low blood pressure, malnutrition, and weak, thinning bones (osteoporosis). If you fall, particularly if you have osteoporosis, you may fracture a bone. Common fractures are those of the hip, wrist, or a bone in the back (vertebra).
Hearing and Vision Deficits
Poor hearing can put you at higher risk for delirium. Not being able to communicate or understand verbal interactions places an older person in a frustrating and isolated state. This can have a detrimental effect on mental functions. If you or someone you are caring for is hard of hearing, make sure to use hearing aids and let healthcare professionals know that you have hearing loss.
Similarly, older people who need eyeglasses or who have impaired vision must make sure that their healthcare providers are aware of the difficulty seeing. If you are going to stay in hospital, take your glasses with you and use them so that you are able to see your environment, the clock, and the individuals caring for you. To avoid episodes of delirium, it is important to be as aware and as comfortable as possible in the stressful environment of the hospital.
You may be less aware that you are dehydrated (suffering from lack of fluids in your body) than before. This is because older people tend not to feel thirsty as readily as they did when they were younger, even though older people tend to have less fluids in their bodies.
A leading cause for dehydration among older adults are water pills (diuretics). In addition to not feeling thirsty, older people may also be at higher risk of dehydration because many take water pills for high blood pressure (diuretics). These pills cause frequent urination. Drinking coffee, tea, or alcohol also causes water to be lost from your body, since these beverages encourage urination. Fever, hyperventilation or diabetes are also capable of causing water loss, as are problems in the digestive tract. Unfortunately, dehydration often goes unrecognized in frail older people.
Being dehydrated puts you at increased risk for becoming delirious. To stay hydrated, drink plenty of fluids. Be particularly vigilant if you are taking water pills (diruetics).
Electrolyte Abnormalities: Hyponatremia, Hypernatremia
As you age, your body loses its ability to keep the amount of water in your body steady (water homeostasis). Specifically, the hormones that keep the salt (sodium) and water balance healthy may not longer work well. You may develop hyponatremia (low sodium level in your blood) or hypernatremia (high sodium level). These two conditions are especially common in nursing homes or hospitals.
- Hyponatremia. This may result from excessive fluids given through an IV or may be due to water pills. Also, your kidneys are less efficient than when you were younger, and therefore, sodium balance is easier to upset in an older person. Also, some drugs are linked to hyponatremia (hydrochorothiazides).
If you experience hyponatremia, you may become confused and develop delirium. However, usually hyponatremia is a mild condition, and can be controlled by restricting fluids and stopping any medicines that may be making the condition worse. Then the underlying cause – be it kidney disease, heart failure, cirrhosis, or some other illness – must be treated promptly.
- Hypernatremia. This condition is usually caused by lack of adequate fluid intake. Hypernatremia can affect your central nervous system and cause symptoms such as: restlessness and irritability, fatigue and lethargy, muscular twitching, increased reflexes, or delirium.
Older people often develop hyperparathyroidism—an overactive parathyroid gland (a gland in your neck). When this happens, you may develop higher than normal levels of calcium in your blood—a condition known as hypercalcemia.
If the calcium levels are only slightly higher than normal, you probably will have no symptoms. However, if the calcium rises to higher levels, delirium may occur, along with nausea, vomiting, fatigue, or confusion.
Hypercalcemia may also stem from a cancerous tumor. Therefore, if you or a loved one exhibits the type of symptoms listed, you must call your doctor promptly.
Hyperparathyroidism is more common in women, especially those over the age of 65 years.
Updated: November 2014
Posted: March 2012