Signs and Causes of Delirium in Elderly

Introduction

Delirium is referred to abrupt changes that occurs in the brain causing individuals to develop emotional disruption and mental confusion which makes people difficult to remember, sleep, be attentive, think effectively and other (Nikooie et al., 2020). The initial signs of delirium in elderly includes hallucination or mood changes, restlessness, agitation, refusal to cooperate and other. The elderly may also suffer from hypoactive delirium in which they remain to seem drowse, show sluggishness, express reduced motor activity and other (Ikegaki and Kizawa, 2020). There are wide variety of causes that leads to development of delirium among the elderly such as drug intoxication, alcohol intake, metabolic imbalances, terminal illness and/or use of certain medications (Leung et al., 2017). The opioids are one such medication which is used for controlling pain among the elderly is seen to cause them delirium. Thus, in this study, the relationship between opioids and delirium development among the elderly is to be explored. In this process, the way opioid-induced delirium impacts the elderly in their everyday life is to be discussed. Moreover, any treatment available for avoiding delirium caused by opioids among the elderly is to be explored so that better health and well-being of the individuals can be determined. Further, detailed search strategy in executing the study is also to be mentioned.

Rationale of the Study

In the UK, the prevalence of delirium among the people in medical ward within the hospital is nearly 20-30% and it is seen that 10-50% of people develop delirium after having surgery (BGS, 2020). The prevalence of delirium is mostly among the elderly which is evident as nearly 14% of the people above the age of 85 years are found to suffer from the issues while accessing care in the nursing home for post-acute care (NICE, 2020). Moreover, in the study by Javedan and Tulebaev (2014), it is mentioned that delirium is commonest issue in the elderly population and 15-25% of the elderly are seen to suffer from delirium after elective surgery and 50% of them suffer from delirium after high-risk healthcare procedures (Javedan and Tulebaev, 2014). Thus, it indicates that most of the elderly are at risk of facing delirium and often after complex surgery in post-operative care environment.

The development of delirium among the elderly is an issue in post-operative care or complex care condition because in most of these situation opioids are used for pain control. The opioids lead to delirium in the adults which affects them to develop disturbed mental state. It is evident as use of methadone which is nature of opioid is seen to get metabolised on entering the body to express neurotoxicity effect which causes delirium (Rengel et al., 2018). The delirium in the elderly is seen to last few days to weeks and many are found to diagnosed late due to inability of timely detection of the health issue. Since opioid is found to one of the key factors related to cause delirium among the elderly, therefore studies are to be explored to determine its true relationship and impact on the health condition of the elderly.

Search Strategy

A literature review is to be developed in the study and for this purpose the electronic search strategy is to be used. This is because it creates opportunity for the researchers in gathering data within less time and money by use of determined keywords in the platform to identify relevant data (Kwok, 2018). In electronic search, many articles related to a single topic from different nations are found to be present in a single platform which can be easily accessed in many occasions to derive data from them to be used in the study. Since many data are freely available, therefore less finances are required in executing the electronic search (Bondarouk et al., 2017). In physical search, physically many book and articles are required to be explored before understanding if they are relevant to the study or not which makes the search more extensive and tiresome along with promotes development of error (Pendergrass and Crawford, 2019). Therefore, the physical search is avoided and electronic search is used as the strategy in gathering data for the study. In addition, no geographical barriers are faced in gathering data through electronic search due to which extensive information are able to be gathered in the study. In this study, the electronic platforms to be used are Goggle Scholar, CINHAL, MEDLINE, Cochrane Library and other. The mentioned platforms are to be used in the study because they contain wide number of medical and healthcare articles from different sources to develop enriched quality study.

Inclusion and Exclusion criteria

The inclusion characteristics are mentioned as the essential and beneficial criteria of the research which are significant to be involved in the study because it supports enhanced data and information relevant to the study to be collected in developing an enriched research (Aronne et al., 2020). However, the exclusion characteristics are referred to the irrelevant aspects of the research which are avoided to be included so that error can be avoided and validity of the study can be ensured (Patino and Ferreira, 2018). The inclusion characteristic in the study are article written in English language, published on and after 2015, qualitative or quantitative or systematic articles, academic and articles contain information regarding opioid-induced delirium among the elderly patients. The exclusion criteria are articles not written in English Language, non-academic, partially available, articles published before 2015 and related to delirium in elderly due to health condition. The articles that are presented and written in English language are to be included and other to be excluded because it is the main language mostly spoken in the UK and known to the researchers due to which they can interpret any information written in English and not in any other language. Since the study is also set in the UK, therefore papers published in English is to be used as it would allow the researchers to develop meaningful interpretation of the data. The articles which are published on and after 2015 is to be inclusive because the article contains most updated data specific to the topic to be explored and allows to create less error in the study to present the findings. The articles published before 2015 is not to be included in the study because they contain backdated information that on addition in the study reduces the reliability and credibility of the research. The articles which can be fully accessible is to be included in the study as it would lead to gather detailed information essential for the topic. The articles with accessible abstract are not to be included as from them only brief data can be gathered which does not allow the researchers to be able to interpret them for explaining it in the study. The articles that are academic is to be involved in the study because it involves experimental data that are gathered through scientific research and have effective evidence for it proof to be true. Thus, its use would lead to enhance the credibility of the study. However, the non-academic articles are to be avoided as they contain data are do not have experimental evidence at time to prove its authenticity and therefor its use may lead to cause error in the study. The primary, as well as secondary articles, are to be used for gathering information in the study because primary articles contain direct data from the participants and secondary article contains data from existing research which can be compared to present enriched findings. The studies that include data regarding opioid-induced delirium in elderly are to be used because they contain valuable data that are relevant to the study topic. The articles related to delirium development in elderly for diseases and other factors are to be excluded as it would lead to cause error in the study.

Data Analysis

The analysis of the gathered data is to be conducted by following thematic analysis. This is because the thematic analysis leads to explore and gather wide amount of data which can be specifically categorised for systematic presentation in the study (Riebschleger et al., 2017). The benefit of using thematic analysis is that it offers freedom to the researcher to theoretically analyse data in flexible manner for its enriched presentation (Riebschleger et al., 2017).

Ethical Considerations

In order to maintain ethical considerations in the study, no falsification of the gathered is to be made. Moreover, each data is to be effectively referred with the author name from whom it has been collected. Further, integrity in the study is to be maintained by honestly presenting the findings without influencing them with own beliefs.

Critical review of Literature

Findings

Theme 1: Opioids versus delirium in elderly individuals

The use of opioids is made for controlling pain in the elderly during surgery or other health issues and it is seen that it creates risk of delirium for the elderly patients. It is evident from the study of Card et al. (2015) which aimed to determine the evolution of the signs of delirium among elderly in the post-anaesthetic care unit (PACU). The study used prospective observational research design in which nearly 400 adult patients were enrolled. The elderly patients emerging out of anaesthesia were evaluated with the help of Confusion Assessment Method for the ICU to determine their delirium signs at PACU admission and during the stay. Multivariable logistic regression is used for assessing impact of opioid exposure on development of delirium. The results informed that opioids are intricately associated with development of delirium in elderly. This is evident as on comparison between the dose of fentanyl administration on the elderly in the PACU it was seen that patient who received 383μg fentanyl expressed 6 times more intricate signs of delirium compared to those that received 50μg fentanyl. However, on comparing between patient who received 383μg fentanyl during their PACU stay to patients who received 383μg fentanyl, it was seen that both expressed similar adjusted odds of developing signs of delirium. In this context, the study concluded that structured monitoring of delirium is require in the PACU for identifying the elderly patient at risk of the condition. The strength of the study is that effective hypoactive and hyperactive signs of delirium is able to be detected in patients as a result of the use of structure delirium tool. However, the lack of presence of larger cohort was a limitation as it could have led to identify additional factor of postoperative condition in patients apart from delirium. In contrast, the study by Daoust et al. (2020) which is a multi-centre prospective study aimed to determine the relationship between use of opioid as pain treatment and delirium in older adults in the emergency department. For this purpose, total of 338patients are included from four hospitals who were aged 65 years and above, were non-delirious, semi-independent or independent in their activity of living and stayed in emergency for more than 8 hours. The results revealed that among patients who mentioned pain intensity about 65 from visual analogue scale (VAS), 26% of the patients faced delirium whereas 11% of the patients faced delirium who has pain intensity score less than 65 in the VAS. However, on comparison with opioid use and delirium in the patients, it is found that there was no significant data that is associated to prove the relation between the two. Thus, it was concluded that pain and not opioid use is responsible for causing delirium in elderly patients in emergency condition. The strength of the study was that robust patients were chosen, and effective control of the environment is reached. However, the limitation of the study is that the research represented only a particular group of elderly patients which is evident as they ignored to include elderly who were suffering from mild to moderate dementia and has lesser functional level (Daoust et al., 2020). In comparison, the study of Swart et al. (2017) which aimed to explore the comparative risk of delirium with different opioids mentioned that there is substantial evidence which ensures opioids are responsible in increasing the risk of adverse outcomes like delirium. In order to prove the mentioned concept, the researchers in the study performed systematic review of existing information through use of MEDLINE in which data is searched by combining opioids and delirium as key terms. In the process six studies are included and all of them were performed in surgical department and the data were gathered through observation. In these studies, the pain and other additional risk factors for delirium was not considered. The results revealed that use of meperidine and tramadol as opioids was highly related with increased risk of patients to suffer delirium. However, the use of fentanyl, codeine, morphine and oxycodone when compared with patients who were not administered any opioid expressed no increase in delirium among the individuals. Meperidine is found to be related with high risk of delirium when compared with tramadol. Moreover, the risk of development of delirium was found to be low in patients who were administered fentanyl or hydromorphone. The strength of the study is the comprehensive search executed to gather valid results whereas the limitation is that comparative aspect in the research is ignored.

Theme 2: Impact of delirium in elderly patients

The presence of delirium in elderly patient is seen to adversely affect their health and we’ll-being. In the study by Mangusan et al. (2015), the researchers explore the outcome of the delirium face by the elderly patient after cardiac surgery. In this process, the researchers gathered 656 cardiac surgery medical records of patients who were mainly elderly as the median age in the study is reported to be 71.4 years. The results revealed that 68.6% of the patients were provided intravenous opioids as medication after the surgery, 43.8% were provided ketorolac and 35.4% were provided benzodiazepines. As a result of medications, increased delirium in patient is reported. The impact of delirium on the patients included greater likelihood of their discharge to any nursing facility rather than home for follow-up care, increased need of care services at home, occurrence of fall, higher need of inpatient physical therapy and prolonged hospital stay. The limitation of the study is that at the initial of the research no standardised tool was used in detecting and measuring delirium in patients which may have led to create error in identification of patient affected by delirium. Moreover, the time of research is not delineated in the study. In similar to the previous study, the article by Brown et al. (2016) aimed to determine the incidence and consequence of delirium after spine surgery among the older adults who are above 70 year of age. For this purpose, 89 adults are recruited in the study who has undergone spine surgery. It was seen that 40.5% of the patients developed delirium and 47.2% of the patients develop hypoactive features related to delirium. The consequence of the delirium includes increased stay in the hospital, higher hospital charge and lower rate of discharge to the home. The severity of the delirium was also found to be related with increased charges at the hospital and lower odds to discharge to home. The limitation of the study is that it is a single centre study due to which the study results cannot be generalised. Moreover, the data are gathered by relying on the hospital charge data and no direct observational data was not included due to which error in data collection if made by the hospital is going to negatively affect the validity of the study. In another study by Dani et al. (2018), the researchers aimed to determine the relation between delirium along with frailty with mortality. For this purpose, the researchers executed exploratory study by using cohort of acute medication admission been made for patient who are above 70 years of age. In the study, the presence of delirium was confirmed by psychiatrist among patients. A standard approach was made to detect the frailty index (FI) of patients and the deaths are notified from the national morality statistics. In total, 710 patient’s data were included in the study. The results revealed that frailty as well as delirium in patients are independently related to higher mortality rates among individuals (delirium: HR 2.4, 95% CI 1.8–3.3, p < .01). The limitation was the study was that the exact psychoactive drugs responsible for causing delirium in the patients were remain unidentified that could also have effect in their development of frailty and increased mortality.

Theme 3: Treatment of opioid-induced delirium in elderly patients

The presence of delirium among the elderly is a common disorder that is caused by opioid use mostly in the post-operative stage and is responsible to hinder the health condition of patients. In this context, the study by Cerveira et al. (2017) is developed that aimed to mention the different pharmacological and non-pharmacological intervention available for managing delirium in elderly patients. For this purpose, systematic review is performed, and the databases used for this purpose include Cochrane, MEDLINE, EMBASE, LILACS and CENTRAL. In the study, total ten article are included. The results informed that sedatives, analgesic medication, alcohol use and others are independent factor of delirium in elderly. In this purpose, the use of combined cognitive impairment management, early mobility, sleep hygiene and hydration care with light therapy is seen to contribute towards enhanced improvement in the functional status and physical restrains of delirium patients. The four studies which identified pharmacological approach in managing delirium in patients mentioned rivastigmine helped to reduce length of delirium in patients as well as improves their cognitive function and burden of care giving on others. The use of olanzapine and haloperidol is seen to lower the delirium severity among patients and droperidol contributes to lower hospitalisation length along with remission rate of delirium. In the study by Sivanesan et al. (2016), the researchers aimed to determine the treatment, diagnosis and pathophysiology of opioid-induced delirium among the elderly. In this study, the systematic review is performed in gathering information from exiting articles. The results regarding treatment of opioid-induced delirium from the review mentions that reduction in the dose of opioid medication for the elderly is effective for them to lower severity of delirium. This is evident as in the existing studies it has been found that 10-50% reduction in opioid medication may led to lower delirium severity in patients. It is also mentioned that managing effective balance of different analgesia which are continuously substituted with different opioids is effective in managing delirium in elderly patients caused by opioid use. The use of opioid antagonists is another effective way to managing delirium and naloxone is the most effective opioid-antagonist to reduce effect of delirium. Moreover, antipsychotic medication can be used in alleviating the delirium signs in patients.

Discussion

The existing studies informed that delirium is serious mental disturbance which results individuals to develop hindered cognitive and mental ability leading them to show confused thinking and reduced awareness regarding the environment. The studies by Swart et al. (2017) and Card et al. (2015) mentioned that opioid has direct relation in causing delirium among elderly patients. The later study by Card et al. (2015) also highlighted that different doe of opioids are responsible for causing increased or decreased severity of delirium in patient. It indicates that dose of opioids has direct relation in raising the severity of delirium to be faced by patients. The fact that opioids and delirium is inter-related because the opioids in reducing pain react on to cause increased dopamine release in the body that in turn creates neurotic effect on the brain cells to leads individuals to develop delirium (Card et al., 2015). Moreover, the study by Swart et al. (2017) highlighted that few of the opioids are regarded as risk for delirium in elderly. In contrast, the study of Daoust et al. (2020) ignored the entire fact of any relation of opioids use and delirium in elderly. The study mentioned it is pain that is the key risk factor for opioids. In the existing two studies of Swart et al. (2017) and Card et al. (2015), the researchers were seen to gather data regarding delirium development in elderly by only focusing on the effect of opioids and ignored the other risk factors such as pain and others. Therefore, there is possibility that opioids may not be the key risk factor of development of delirium in the elderly and instead pain and sleeping patterns and other have much higher impact in causing delirium. In addition, the studies by Mangusan et al. (2015) and Brown et al. (2016) mentioned that opioid-induced delirium among the elderly causes them to face extended hospital stay, reduced transfer to home, increased transfer to nursing facility and high healthcare cost. This is evident as delirium lead individuals to be mentally incapable to take their own care or follow care instructions to self-support. Therefore, to keep the patients under observation and support their care in the delirium condition leads to cause the patient to extend their stay at the hospital and not been transferred to home. This in turn increases the cost of care as nurses are to be hired as well as hospital or nursing home bed is occupied by the elderly to access support to resolve and manage delirium to be gain full empowerment of their health management. In addition, the study by Dani et al. (2018), highlighted that delirium could lead individual to develop mortality. This is evident as delirium cause individuals to be frail making them unable to take care in any emergency situation and express chances of unnecessary falls out of raised confusion due to delirium that may contribute towards their fatality. The further studies by Cerveira et al. (2017) mentioned that sleep hygiene, cognitive impairment management and other are effective to reduce severity of delirium. This is evident as sleep disturbances is the modifiable risk factor for increase delirium as it contributes to hindered brain functioning out of lack of rest. However, maintaining sleep hygiene would led to create calm impact on the brain which is able to avoid severity of delirium (Cerveira et al., 2017). Moreover, cognitive impairment helps to resolve the impact of delirium as it led the elderly to realise the reality and differentiate between negative and positive thought. The facts are supported by the study of Sivanesan et al. (2016) who also mentioned them to be non-pharmacological intervention in managing and controlling delirium in individuals. The intervention available in treatment of delirium of individuals includes change in dose of opioids which is also evident from the study of Card et al. (2015) where it was mentioned that lower dose of opioids are causes reduced delirium.

Recommendations

The recommendation developed from the existing studies is that effective monitoring of the elderly patients suffering from delirium is to be made. This is because often late prognosis of delirium is elderly is made which causes complexity in delivering care to them. Moreover, the enhanced monitoring of delirium is important for the elderly to help them have adequate and early rehabilitation at home and diminish the chances of loss of life. It is also required for the faster recovery of patients and reduce their long hospital stay along with healthcare cost which is raised by inappropriate management and monitoring of care for delirium of the elderly. The other recommendation is that elderly with dementia are to be encouraged to have increased rest and sleep to support improved cognitive function of the brain in avoiding hallucinations. Moreover, they are recommended to remain in calm and quite environment as well as ensure they are comfortable in care to avoid severity of delirium. The elderly with delirium are to be involved in therapeutic session with the physical or occupational therapist to help them understand the way the health resources are to be managed for them to make them empowered to take their own care. The other suggestion is that delirium in elderly are to be managed by changing the dose of opioids and administration of anti-psychotic drugs. This is because the opioids cannot be entirely stopped in the patients as that would lead to elevated pain perception in the pain in turn making them faced hindered well-being.

Limitations

The initial limitation of the study is time constraint due to which extensive research could nor be performed to gather more enriched and enhance data for presentation in the review. The other limitation is the failure to perform primary researcher in gathering relevant data through direct interaction and observation of the elderly who are currently suffering from delirium because of post-operative impact of opioids. Moreover, due to financial constraints many relevant literatures could not be accessed that is another limitation in the study. This is because the relevant studies could help to create broader idea regarding the mentioned topic.

Conclusion

The above discussion mentions that opioid is related to cause delirium among elderly in the post-operative care condition. The impact of the delirium leads the elderly to experience longer hospital stay, increased medical cost, lack of empowerment, unable to remain at home care and other. The treatment available in improving the opioid-induced delirium include lowering the dose of opioids, improving sleep patterns and others.

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