Geropsych SIG Pearl: Assessing Cardiovascular Risk in Older Adults with Delirium
By George Peraza-SmithBy George Peraza-Smith
Delirium in older adults is a medical emergency, often under-recognized despite its association with significant morbidity and mortality. As APRN gerontological specialists, we must understand not only the common signs and symptoms of delirium but also the cardiovascular causes and risk factors that can exacerbate this acute state of confusion.
Delirium presents as a rapid change in cognition, characterized by a reduced ability to focus, sustain, or shift attention. It is a syndrome of fluctuating consciousness, with alterations in perception, impaired short-term memory, and disorganized thinking (Ramírez Echeverría et al., 2022). These symptoms often manifest suddenly, over hours or days, and fluctuate throughout the day. It's important to note that while agitation and restlessness are classic signs, delirium can also present as lethargy and inactivity.
Cardiovascular diseases are a common underlying cause of delirium. Conditions such as heart failure, arrhythmias, myocardial infarction, and valvular disease can precipitate delirium, particularly in older adults (Francis & Young, 2023). The reduced cardiac output and consequent cerebral hypo-perfusion lead to a decreased supply of oxygen and nutrients to the brain, disrupting its function.
The cardiovascular risk factors that contribute to delirium are multifaceted. Hypertension, diabetes, hyperlipidemia, and a history of stroke or transient ischemic attack increase the vulnerability of the brain to the acute insults that trigger delirium. Furthermore, peripheral vascular disease and chronic heart diseases, which compromise the blood flow to the brain, can also be significant contributors (McPherson et al., 2013).
In the context of delirium, these risk factors not only predispose older adults to the development of the condition but can also worsen the clinical course and outcome. It is critical to manage these risk factors proactively. This includes optimizing blood pressure, managing arrhythmias, ensuring adequate hydration, and monitoring for signs of myocardial infarction or heart failure.
As APRN Gerontological Specialists, our role extends beyond recognition. We must engage in meticulous assessment, identifying and treating underlying cardiovascular causes, and implementing strategies to prevent delirium. This involves a thorough review of the patient’s medication, as polypharmacy and certain drugs can increase delirium risk. Additionally, we must consider environmental factors such as sensory deprivation or overload, which can precipitate delirium, and address them accordingly.
In summary, delirium in older adults is a complex interplay of multiple factors, with cardiovascular health having a pivotal role. As frontline APRN providers, we must integrate a cardiovascular risk assessment into our evaluation of older adults presenting with delirium, adopting a holistic approach to management and prevention. By doing so, we not only improve the immediate care of our patients but also contribute to better long-term outcomes.
George Peraza-Smith, DNP, GNP-BC, GS-C, FAANP
Gbyronsmith@gmail.com
References
Francis, J. & Young, G.B. (2023). Delirium (beyond the basics). UpToDate.
https://www.uptodate.com/delirium-beyond-the-basic
McPherson, J.A., Wagner, C.E., Boehm, L.M., Hall, J.D., Johnson, D.C., Miller, L.R., … Pandharipande, P.P. (2013). Delirium in the cardiovascular ICU: Exploring modifiable risk factors. Critical Care Medicine, 41(2), 405-13.
https://doi.org/10.1097/CCM.0b013e31826ab49b1
Ramírez Echeverría, M.d.L., Schoo, C., & Paul, M. (2022). Delirium. StatPearls.
https://www.ncbi.nlm.nih.gov/books/NBK470399/