Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia

Delirium occurring in a patient with preexisting dementia is referred to as delirium superimposed on dementia (DSD). DSD commonly occurs in older hospitalized patients and is associated with worse outcomes, including higher rates of mortality and institutionalization, compared to inpatients with delirium or dementia alone. This narrative review summarizes the screening, diagnosis, management, and pathophysiology of DSD and concludes by highlighting opportunities for future research. Studies were identified via Medline and PsycINFO keyword search, and handsearching reference lists. Conceptually, DSD could be considered an "acute exacerbation" of dementia precipitated by a noxious insult akin to an acute exacerbation of heart failure or acute on chronic renal failure. However, unlike other organ systems, there are no established biomarkers for delirium, so DSD is diagnosed and monitored clinically. Because cognitive dysfunction is common to both delirium and dementia, the diagnosis of DSD can be challenging. Inattention, altered levels of arousal, and motor dysfunction may help distinguish DSD from dementia alone. An informant history suggestive of an acute change in cognition or alertness should be investigated and managed as delirium until proven otherwise. The key management principles include prevention, identifying and treating the underlying precipitant(s), implementing multicomponent interventions to create an ideal environment for brain recovery, preventing complications, managing distress, and monitoring for resolution. Informing and involving family members or caregivers throughout the patient journey are essential because there is significant prognostic uncertainty, including the risk of persistent cognitive and functional decline following DSD and relapse. Furthermore, informal carers can provide significant assistance in management. Emerging evidence demonstrates that increased exposure to delirium is associated with neuronal injury and worse cognitive outcomes although the mechanisms through which this occurs remain unclear. Given the clinical overlap between delirium and dementia, studying shared pathophysiological pathways may uncover diagnostic tests and is an essential step in therapeutic innovation.