Guidelines for a Palliative Approach in Residential Aged Care

ACATs also use comprehensive assessment to screen for cognitive impairments, particularly
dementia, and other mental illnesses, such as depression. This assessment includes the MMSE
to screen for dementia, accompanied by a detailed history. [293] The team also includes carers,
when available, to assist in the process of assessment and to provide history and care preferences
for the person being assessed.
7.4 DELIRIUM
Delirium refers to a clouding of consciousness, which is primarily “characterised by disordered
attention, thinking, and perception” [294, p. 696] (Level IV). The severity of the delirium fluctuates
and can worsen after dark. [295] Most prevalence studies of delirium have been conducted in
hospitals with medically ill people, in whom the prevalence rate was about 25% [295] (Level EO).
Delirium may involve paranoid ideas, which may manifest as an idea that the food has been
poisoned, for example. Residents with delirium may be noisy, demanding or aggressive, which
may upset or harm others. Family members or care providers may report a rapid and drastic
decline in the resident’s functioning, which is useful in distinguishing delirium from dementia.
7.4.1 Assessment
One study explored the course of delirium in 193 older persons in acute care and found that
the symptoms of delirium (e.g. inattention, disorientation, and impaired memory) were present
up to 12 months following diagnoses for older persons with or without dementia [294] (Level
IV). Despite this similarity, the researchers’ reported that the duration of the first episode
of delirium was longer for those with dementia compared with those who had no cognitive
impairment at baseline measurements. Additionally, a longer initial episode of delirium was
predictive of a worse prognosis such as long-term functional and cognitive disabilities.
Although, the focus of the study was an acute care setting, the findings are likely transferable
to the aged care context. [294] For example, the researchers’ reported difficulty in distinguishing
delirium from dementia with many participants diagnosed as having both disorders, which
is the same issue that aged care team members have in Australian RACFs. [293] Therefore, a
thorough assessment of symptoms is required, which includes consideration of the persistence
of symptoms (e.g. inattention, disorientation, and impaired memory) [294] (Level IV). Those
residents with dementia are likely to have these three symptoms plus a gradual decline in their
ability to undertake the activities of daily living. Those residents with delirium while have
the same three symptoms are more likely to have a sudden deterioration in their capacity to
complete the activities of daily living [294] (Level IV).
The following table provides some indicators to assist aged care team members in distinguishing
delirium from dementia. This table is provided as a guide only and it is recommended that an
expert in psychiatric disorders such as a geriatrician, geropsychologist or a psycho-geriatrician is
consulted for diagnostic purposes.
124 Guidelines for a Palliative Approach in Residential Aged Care