Choosing Wisely:

Don’t assume a diagnosis of dementia in an older adult who presents with an altered mental status and/or symptoms of confusion without assessing for delirium or delirium superimposed on dementia using a brief, sensitive, validated assessment tool.

Rationale and Comments: Delirium is common in older adults, especially in the hospital setting, yet delirium is frequently unrecognized and not documented by nursing or medical staff. Delirium occurs in as much as 50% of older adults in the hospital, and delirium superimposed on dementia occurs in as high as 90% of hospitalized older adults. Delirium is associated with very poor clinical outcomes, including prolonged length of stay, high costs and lower quality of life for older adults when not detected early. Delirium is treatable and often reversible and dementia is not, so mislabeling older adults with dementia may miss a life-threatening underlying condition causing the delirium such as an infection, medication side effect, or subdural hematoma. Delirium is extremely costly to the health care system and to society with estimates ranging from $143 to $152 billion annually. Nurses and physicians often fail to recognize delirium. Only 12% to 35% of delirium cases are detected in routine care, with hypoactive delirium and delirium superimposed on dementia most likely to be missed.
Sponsoring Organizations:
  • American Academy of Nursing
  • Sources:
  • Expert consensus
  • Disciplines:
  • Psychiatric and Psychologic
  • Geriatric Medicine
  • References: • Voyer P, Champoux N, Desrosiers J, Landreville P, McCusker J, Monette J, Savoie M, Richard S, Carmichael PH. Recognizing acute delirium as part of your routine [RADAR]: a validation study. BMC Nurs. 2015 Apr 1;14:19.
    • Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014 Mar 8;383(9920):911-22.
    • Fick DM, Steis MR, Waller JL, Inouye SK. Delirium superimposed on dementia is associated with prolonged length of stay and poor outcomes in hospitalized older adults. J Hosp Med. 2013 Sep;8(9):500-5.
    • Steis MR, Fick DM. Delirium superimposed on dementia: accuracy of nurse documentation. J Gerontol Nurs. 2012 Jan;38(1):32-42.
    • Kolanowski AM, Fick DM, Yevchak AM, Hill NL, Mulhall PM, McDowell JA. Pay attention! The critical importance of assessing attention in older adults with dementia. J Gerontol Nurs. 2012 Nov 15;38(11):23-7.
    • Leslie DL, Inouye SK. The importance of delirium: economic and societal costs. J Am Geriatr Soc. 2011 Nov; 59 Suppl 2:S241-3.
    • Williams KN, Herman RE. Linking resident behavior to dementia care communication: eff of emotional tone. Behav Ther. 2011 Mar;42(1):42-6. doi: 10.1016/j. beth.2010.03.003. Epub 2010 Oct 1.
    • Fick DM, Hodo DM, Lawrence F, Inouye SK. Recognizing delirium superimposed on dementia: assessing nurses’ knowledge using case vignettes. J Gerontol Nurs. 2007 Feb;33(2):40-7.

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