Delirium Affects All Ages
Delirium is an abrupt, fluctuating disturbance in attention and cognition caused by a medical condition, intoxication, or withdrawal. While older adults are most vulnerable, the condition can manifest in individuals of any age. Its underlying causes often vary dramatically with age, from congenital issues in infants to complex medical histories in seniors. Recognizing that delirium is a lifespan issue is crucial for timely diagnosis and management, which can significantly improve outcomes and prevent long-term complications.
Delirium in the Youngest Populations
Delirium can occur in infants and children, especially those in intensive care settings, though it can be difficult to recognize and assess due to developmental differences. Symptoms may present differently than in adults and are often mistaken for normal developmental behaviors or distress. This is a critical distinction, as pediatric delirium is associated with longer hospital stays and can have long-term cognitive and emotional impacts.
Causes in infants and children
- Infection, including high fever
- Hypoxia (low oxygen supply to the brain)
- Metabolic disturbances or electrolyte imbalances
- Medications, such as sedatives or pain relievers
- Underlying critical illness or surgery
- Sleep-wake cycle disruption
Recognizing pediatric delirium
Because children cannot always verbalize their confusion, diagnosis often relies on observation of behavioral and mental status changes, including:
- Inattention or difficulty concentrating
- Changes in sleep patterns
- Irritability or emotional distress that is difficult to soothe
- Agitation or restlessness
- Hallucinations, such as seeing or hearing things that aren't there
- Confusion about familiar people or surroundings
Delirium in Young Adults
In younger adults (typically 18-64), delirium is less common but often signals a severe, life-threatening issue that requires immediate medical attention. Unlike in seniors, where chronic conditions may predispose to delirium, younger adults typically develop it due to acute and significant stressors.
Key causes in young adults
- Severe systemic infection, such as sepsis
- Substance intoxication or withdrawal, including alcohol or illicit drugs
- Medication side effects, particularly sedatives or anticholinergics
- Traumatic brain injury
- Electrolyte imbalances or organ failure (e.g., liver or kidney)
- Post-surgical complications
Studies show that younger adults with hospital-acquired delirium may have different outcomes than older adults, including higher rates of discharge home but similar lengths of hospital stay and costs.
Delirium in Older Adults
Older adults are the most vulnerable and most frequently affected by delirium, with incidence rates significantly higher in hospitalized or institutionalized populations. For those with pre-existing conditions like dementia, the risk is even greater, a phenomenon known as delirium superimposed on dementia (DSD). The condition is often overlooked or misattributed to age-related cognitive decline, making prompt recognition critical.
Major risk factors in the elderly
- Advanced age, frailty, and pre-existing cognitive impairment (dementia)
- Chronic illnesses and multiple comorbidities
- Sensory impairments (vision, hearing)
- Acute illness, particularly infection (e.g., UTI, pneumonia)
- Surgery, especially cardiac or hip fracture repair
- Polypharmacy (taking multiple medications)
- Dehydration, malnutrition, or pain
- Environmental changes (e.g., hospitalization)
Comparing Symptoms of Delirium Across Age Groups
| Symptom | Children and Infants | Younger Adults | Older Adults |
|---|---|---|---|
| Inattention | Apathy or agitation common; less focused than usual. | Difficulty concentrating, easily distracted. | Inability to pay attention, mind wanders. |
| Disorientation | May not recognize familiar people or places. | Can be disoriented to time, place, or person. | Often presents as confusion about time and place. |
| Hallucinations | Reported in pediatric studies, similar rates to adults. | Can experience frightening visual hallucinations. | Visual or tactile hallucinations are common. |
| Mood Changes | Irritability, lability, or withdrawal is common. | Can become irritable, agitated, or withdrawn. | Can present as quiet and withdrawn (hypoactive) or agitated (hyperactive). |
| Sleep Disturbance | Reversed sleep-wake cycle, excessive sleep or insomnia. | Restless sleep or reversal of sleep-wake cycle. | Disrupted sleep patterns, "sundowning" is common. |
| Memory Deficits | Difficulty with concentration affects recent memory. | Difficulty recalling recent events or information. | Impaired memory for recent events is a key feature. |
| Key Triggers | Infection, meds, low oxygen, high fever. | Substance use/withdrawal, infection, trauma, medication. | Infection, dehydration, surgery, sensory impairment. |
Diagnosis and Management at Every Age
Diagnosing delirium involves recognizing an acute change in mental status and identifying the underlying cause. Screening tools like the Confusion Assessment Method (CAM) exist in versions adapted for different age groups, such as the pediatric CAM-ICU (pCAM-ICU) and versions for use in older adults.
- Identify the Trigger: A thorough medical history, physical exam, and lab tests are used to pinpoint the root cause, such as infection, dehydration, or medication issues.
- Treat the Cause: Once identified, treating the underlying medical condition is the most effective way to resolve the delirium.
- Provide Supportive Care: Non-pharmacological interventions are the first-line treatment and are critical for patient safety and comfort. These include maintaining a calm environment, reorienting the patient with familiar items, and ensuring proper hydration and nutrition.
- Consider Medications with Caution: Medications should be used sparingly and only when necessary to manage severe agitation that poses a risk to the patient or others, especially in older adults where they can prolong delirium.
Preventative Strategies Across the Lifespan
In many hospital settings, a significant percentage of delirium cases are preventable through multifactorial, non-pharmacological interventions. The core strategies focus on addressing modifiable risk factors and creating a supportive environment.
- Maintain optimal health: Ensure adequate hydration, nutrition, and treat pain effectively.
- Optimize senses: For those with sensory impairments, ensure they have and use their eyeglasses and hearing aids.
- Promote mobility: Encourage physical activity as early as possible to prevent deconditioning.
- Regulate sleep: Minimize disruptions to promote a regular sleep-wake cycle.
- Engage and orient: Provide cognitive stimulation and frequent reorientation with clocks, calendars, and family photos.
- Medication review: Regularly review medications, particularly in older adults, to identify and adjust those that may cause delirium.
For more detailed guidance, the Hospital Elder Life Program (HELP) offers a structured approach to prevention in older hospitalized patients.
Conclusion
Delirium is not limited to older adults; it is a critical, acute brain dysfunction that can impact any individual, from newborns to the most elderly. While it is more prevalent in seniors, particularly in hospital settings, its occurrence in younger populations should be recognized as a serious indicator of an underlying medical problem. Timely diagnosis, swift identification and treatment of the underlying cause, and the implementation of supportive, non-pharmacological care are essential to ensuring a full and rapid recovery, regardless of the patient's age.
