Dementia and Delirium Evaluation

5 Things Doctors Will Look for When Evaluating Someone With Delirium
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If you've reported to a doctor or nurse that a loved one with dementia seems more confused than usual or is showing other signs of delirium, the correct next step is to make sure the person is evaluated by a doctor as soon as possible, ideally the same day.

Here's what a thorough medical evaluation will likely cover when delirium is suspected in someone with dementia.

Remember that you're a key participant in the process, because you can supply important information that the doctor won't know and your loved one may not be able to convey. If some of the following points are overlooked in a medical evaluation, don't be shy about asking the doctor why.

1. The doctor should assess for underlying illnesses.

Why: In some people with dementia, delirium may be the only outward sign of an underlying illness. Just about any physical problem that stresses the body can cause delirium in a person with dementia.

To check for illness, the doctor will take a medical history and do a basic physical -- and will also usually:

  • Check for signs of infection, such a urinary tract infection (UTI) or pneumonia.

  • Assess blood pressure, pulse, breathing rate, and blood oxygen level, which can help determine whether a problem with the heart or lungs is at the root of things. Blood pressure and pulse rate can also provide clues to whether dehydration might be present.

  • Possibly order an EKG and/or chest X-rays. This step depends on whether the clinician thinks it's medically indicated and whether another likely cause of delirium has been found (such as signs of UTI on a urine dipstick).

What can be done: If an illness is the main cause of delirium, treatment of the problem usually helps improve the sick person's mental state. (Even after successful treatment of an illness, however, it can still take days or even longer for the person's mental state to get back to what's normal for him or her.)

2. The doctor should assess for excessive pain or other discomfort.

Why: Unresolved pain is another reason the body can be stressed to the point of delirium. The doctor will explore for possible causes of pain:

  • Was there a fall? Are there signs of injury? Falling down sometimes causes unrecognized fractures that cause pain. Dementia may cause the person to forget the incident and -- except when moving a certain way -- the pain, which means he or she doesn't mention it and suffers unnecessarily.

  • Could the person be constipated? Constipation, too, can create pain that a person with dementia is unable to connect to bowel habits, or even articulate. In older men with enlarged prostates, urinary retention can lead to severe pain.

What can be done: Many causes of pain, such as fractures and constipation, can be treated, easing some of the pain over time. Meanwhile, carefully prescribed painkillers can ease the physical stress of pain and help resolve the delirium.

More things doctors should evaluate when someone with dementia becomes delirious

3. The doctor should review all medications the person has been taking.

Why: Certain medications have been linked to delirium in older adults because they can easily cause drowsiness or confusion. Particular attention should be paid to those known to contribute to delirium. These include:

  • Medications from a class known as anticholinergics, such as medications for overactive bladder, itching/allergy, vertigo, and nausea

  • Opiate pain medications, especially if they're a new or recent prescription

  • Other psychoactive drugs, including sedatives/tranquilizers (Ambien, Valium, Ativan), antipsychotics (Haldol, Risperdal), and tricyclic antidepressants for nerve pain or depression

Be sure you also discuss over-the-counter medications with the doctor. PM-formulas for night use usually contain antihistamines, for example, which often cause increased confusion in people with dementia.

What can be done: The doctor should try to eliminate concerning drugs or reduce dosages if possible. If no change is made in your loved one's roster of medications, be sure the doctor explains why, especially if your loved one is taking one of the type of medications listed above.

4. The doctor may consider blood work.

Why: Abnormalities in blood chemistry, such as a high or low blood sodium level, can cause delirium. An abnormal blood count can also point to an underlying infection or other illness.

The doctor may order a partial or complete workup covering blood count, electrolytes, kidney function, glucose, and thyroid function.

What can be done: Ask the doctor to explain any abnormalities found in blood work results, whether they might be related to delirium, and what the plan is for addressing them.

5. The doctor may ask about emotional stressors.

Why: Especially if no physical illness or medication side effect is identified, the doctor may ask about new emotional stressors for the person with dementia. Emotional trauma can take a physical toll. Common stressors that can trigger delirium include a change in living environment, a change in caregiver, or the death of a spouse or companion.

What can be done: If emotional stressors seem to be at the root of the sudden decline in functioning, you'll need to work on a plan to restore as much stability and comfort as possible while your loved one adjusts to the change.

A thorough assessment for delirium usually uncovers a likely trigger. It's common for several triggers to be present at the same time.

After a medical assessment for delirium

Be sure you understand the plan to treat or eliminate the delirium trigger or triggers. Don't leave the doctor without this discussion. It's also often a good idea to request a follow-up visit (or at least a follow-up phone call) in one to two weeks, to make sure the delirium has resolved or is resolving -- and to get advice if it's not.

Even when a delirium trigger (such as a urinary tract infection) is being properly treated, it may take days or longer for your loved one's delirium to completely resolve. To help this process along and reduce the chance of complications such as falls or injury, learn supportive tips for what caregivers can do for someone with dementia who has delirium.