Delirium After Stroke Results in Poorer Outcomes

A review by Shi et al. (2012) verifies that delirium develops in almost one-third of stroke patients and that the presence of delirium is associated with poorer outcomes.

The researchers looked at 10 different studies, which included more than 2000 patients who had suffered an ischaemic or haemorrhagic stroke. They examined four different outcome parameters: length of stay, care required following discharge, inpatient death rates and survival rates one year after the stroke had occurred. The researchers made some startling discoveries, including the following:

• Individuals who developed delirium were 4.7 times as likely to die in hospital or within the year following the stroke;
• The incidence of delirium ranged between 10 and 28% in most studies, however, one study showed an incidence of 48%; and
• Individuals who developed delirium tended to stay in hospital an average of nine days longer and were three times more likely to be discharged to a long-term care facility.

(Shi et al. 2012)

Although delirium can occur any time after a stroke and may be part of the presentation of the stroke, it is often caused by medications, infection, heart failure or metabolic abnormalities. The researchers stress that it is important to determine the cause of delirium in order to improve patient outcomes (Shi et al. 2012).

The study also found that individuals who experience delirium tend to be older, experience larger strokes affecting larger portions of the brain and have more comorbidities; factors that may explain the poorer outcomes seen in this meta-analysis (Shi et al. 2012). Identifying delirium earlier and managing it appropriately when it does occur could improve patients’ quality of life and help them to maintain their independence for longer.

What is Delirium?

Delirium can be defined as severe and rapid changes in brain function that may occur as a result of mental or physical illness. It is generally reversible and temporary.

What Causes Delirium?

As mentioned above, medications, infection, heart failure and metabolic disorders can cause delirium. Other causes include withdrawal from drugs or alcohol (or drug abuse), surgery, toxins or poisons, and conditions that cause the brain to be deprived of oxygen (stroke is a common cause of oxygen deprivation). (Mayo Clinic 2020).

What are the Symptoms of Delirium?

Delirium manifests as a drastic change in personality, behaviour, speech, memory, mood and/or movement, including:

• Rapid changes in mental state (i.e. between agitation and lethargy);
• Changes in level of alertness or consciousness;
• Changes in perception and feeling;
• Changes in movement (i.e. hyperactivity alternating with somnolence);
• Changes in patterns of sleep;
• Disorientation;
• Changes in memory (both short-term recall as well as memory, including anterograde and retrograde amnaesia related to onset of delirium);
• Difficulty concentrating;
• Incoherent or abnormal speech patterns;
• Changes in personality;
• Restlessness; and
• New-onset incontinence.

(Mayo Clinic 2020; NSW DoH 2020)

How is Delirium Treated?

Treatment must be focused on determining the cause of the delirium and reversing it. The patient’s environment should be soothing, quiet, comfortable, safe and non-threatening. Medications should be reviewed, and any that may worsen confusion should be discontinued. Finding and treating the cause is paramount and may require an active and all-inclusive search for the cause of the delirium (Mayo Clinic 2020).

Patients may require medications to control and improve symptoms. In addition, frequent reorientation and behavioural modification may be of benefit (Mayo Clinic 2020).

How Long Does Delirium Usually Last?

Fortunately, delirium usually only lasts for a few days, although it may last for weeks or months in some cases (VIC DoH 2015). Most of the time, patients will recover completely. In some cases, delirium will progress or fail to resolve; these patients may require care for the rest of their lives (Mayo Clinic 2020).

Conclusion

Delirium is a common occurrence, particularly in stroke patients. Finding and reversing the cause is the most important step in treatment. While the patient is in a delirious state, they must be kept calm and should be provided with a soothing environment. Predicting which patients are at high risk of delirium will allow caregivers to quickly identify and treat this potentially devastating complication.

Additional Resources

• Delirium Awareness and Cognitive Impairment
• Postoperative Delirium

References

• Mayo Clinic 2020, Delirium, Mayo Clinic 2020, viewed 5 November 2020, https://www.mayoclinic.org/diseases-conditions/delirium/symptoms-causes/syc-20371386
• New South Wales Department of Health 2020, COVID-19 and Delirium, NSW DoH, viewed 5 November 2020, https://www.health.nsw.gov.au/Infectious/covid-19/communities-of-practice/Pages/guide-delirium.aspx
• Shi, Q, Presutti, R, Selchen, D & Saposnik, G 2012, ‘Delirium in Acute Stroke’, Stroke, vol. 43 no. 3, viewed 28 October 2016, https://www.ahajournals.org/doi/10.1161/STROKEAHA.111.643726
• Victoria Department of Health 2015, Delirium is a Serious Condition, VIC DoH, viewed 5 November 2020, https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/older-people/cognition/delirium/delirium-serious