Delirium according to DSM-IV is a common complication after stroke and in patients treated for hip fractures. Delirium is characterized by disturbance of attention and consciousness, which develops over a short period of time and symptoms tend to fluctuate during the course of the day. Delirium is probably the most common presenting symptom of disease in old age. Hypoxemia and hypercortisolism are important pathophysiologic mechanisms.
In a previous study we found to our surprise that morning delirium was especially common and occurred in 148/315 (47%) delirious older patients cared for in different types of care. In another study we found a close association between hypoxemia and delirium in patients admitted to hospital for hip fractures. Hypoxemia on admission mainly occurred among patient who had fallen during the night. We have also found in an unpublished study that 50% of patients admitted to our geriatric hip-fracture rehabilitation unit had sleep apnea syndrome. In a recently published paper we found that delirium was associated with sleep apnea syndrome in stroke patients admitted to our geriatric stroke rehabilitation unit in mean two weeks after their stroke. Those stroke patients with sleep apnea syndrome also had significantly more leucoaraiosis.
These stroke patients with sleep apnea syndrome were randomized to treatment with nasal Continous Positive Air Pressure (nCPAP) or to control group who received nCPAP treatment after 4 weeks. Compliance to the nCPAP treatment was very poor in the stroke patients with delirium and the treatment effect was not significant on group level. However several patients with delirium who complied with the treatment recovered from their delirium. When performing a literature search we found that the same results had been achieved in three published case reports but on other types of delirious patients with sleep apnea syndrome. The main effect on group level in our treatment study was, however, a significant reduction of depressive symtomatology.
Hypoxemia is a common and often easily treated cause of delirium in older patients admitted to hospital. Especially cerebral hypoxemia caused by i.e. sleep apnea syndrome, anemia, hypotension, pulmonary diseases, and heart failure can often easily be prevented and treated. The combination of hypoxemia and hypercortisolism is probably especially dangerous to the brain which probably have implications both for the nursing and medical care of the older patient.
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