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Clinical Review Clinical review

Delirium in older people

BMJ 2007; 334 doi: (Published 19 April 2007) Cite this as: BMJ 2007;334:842

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Delirium: a common cause of misdiagnosis in the elderly

We have read with pleasure the Clinical Review “Delirium in older people”
by Young and Inouye (1). Delirium is one of the great geriatric syndromes,
very common in the emergency department and hospitalization wards in our
“Dr. Gustavo Aldereguía Lima” Teaching Hospital in Cienfuegos, where more
than 15% of the population is 60 years and over.

Delirium prevalence in hospitalized elderly patients varies from 10 to 15% at
admission, and 5 to 40% post-admission. In frail hospitalized elderly patients it
is reported near 60% of cases, and it constitutes an episode that enlarges
the stay at the hospital and has high complication rates, which are
often lethal. (2,3)

Many medical doctors misdiagnose and mistreat delirium. At the same time
they contribute to increasing its frequency by prescribing drugs that are
some of the precipitating and aggravating factors in older persons, in whom
cognition is their most vulnerable function.

We consider that main causes of diagnoses error are: (4)

• To ignore that delirium could be the unique clinical manifestation of a
very serious illness

• To confuse delirium with dementia

• To believe that the clinical picture only includes agitation,
hallucinations, and behavioural disorders, while lethargy and diminishing
activity are frequent in the elderly (hypoactive delirium)

• To misevaluate the fluctuating evolution because during some lucid
periods the patients would appear normal.

Clinical Review by Young and Inouye (1) illustrates the
differences between delirium and dementia, and how these two conditions
coexist and it is possible that they overlap.
Usually dementia is characterized by its insidious onset, long duration,
lucid awareness level, normal attention (less in severe cases), relatively
stable during 24 hours, absence of hallucinations, and poor reversibility.

On the other hand, delirium starts suddenly, it has short length, confused
awareness level, incorrect attention, fluctuating during 24 hours, with
nocturnal exacerbation, frequent hallucinations, and many times reversible
if the underlying cause is removed or ameliorated.
All these considerations are better understood by geriatricians. However,
elderly patients are attended more and more by specialists of very different
branches at hospitals. So, the solution for better care for this
increasing group is an approach that includes the education of all medical
doctors in the management of common elderly syndromes as delirium is.
We welcome that the British Medical Journal, a prestigious general journal,
published this review article to share present ideas about this important

Old people with acute conditions required quick and precise medical
care. Misdiagnosis in delirium carries catastrophic consequences and
definitively aggravates the prognosis of the patients, because of not treat
or mistreat a potential reversible condition.

Ángel J. Romero-Cabrera, MD, Associate professor,

Alfredo D. Espinosa Brito, MD, PhD, professor

Internal Medicine and Geriatric Department
Teaching Hospital “Dr. Gustavo Aldereguía Lima”, Cienfuegos, Cuba


1. Young J, Inouye SK. Delirium in older people. BMJ 2007;334:842-846

2. Altimir S, Prats M. Síndrome confusional en el anciano. Med Clin (Barc)

3. Ribera Casado JM. El síndrome confusional agudo: Un “síndrome
geriátrico” en alza. Rev Clin Esp 2005;205(10):469-471

4. Romero-Cabrera AJ. Temas para la asistencia clínica del Adulto Mayor
(in press)

Competing interests:
None declared

Competing interests: No competing interests

24 April 2007
Ángel J Romero-Cabrera
MD, Associate Professor
Alfredo D. Espinosa-Brito, MD, PhD, Professor
Teaching Hospital