From the Guidelines
A comprehensive delirium workup for an 89-year-old without specific symptoms should begin with a thorough clinical assessment using validated tools like the Confusion Assessment Method (CAM) or 4AT to confirm delirium, as recommended by the most recent guidelines 1.
Initial Evaluation
The initial evaluation should include:
- Complete blood count
- Comprehensive metabolic panel
- Urinalysis
- Chest X-ray
- Electrocardiogram to identify common causes such as infections, electrolyte abnormalities, or medication effects
Medication Review
Review all medications, particularly anticholinergics, benzodiazepines, and opioids, as these frequently trigger delirium in older adults 1. Obtain a detailed medication history including recent changes and over-the-counter supplements.
Neuroimaging and Additional Testing
Consider neuroimaging (CT or MRI) to rule out stroke or intracranial pathology, especially with new neurological findings. Additional testing may include thyroid function tests, vitamin B12 levels, ammonia levels, arterial blood gases, and toxicology screening based on clinical suspicion.
Physical Examination and Non-Pharmacological Interventions
Perform a thorough physical examination focusing on vital signs, hydration status, neurological findings, and signs of infection or organ dysfunction. Assess for sensory impairments and ensure appropriate glasses and hearing aids are available. Implement non-pharmacological interventions immediately, including reorientation strategies, maintaining day-night cycles, ensuring adequate hydration, and involving family members. Avoid physical restraints and minimize unnecessary procedures.
Management of Delirium
The management of delirium should focus on treating the underlying cause, and pharmacological interventions such as haloperidol or other antipsychotics may be used to control symptoms, as recommended by recent guidelines 1. This comprehensive approach addresses the multifactorial nature of delirium in older adults, where the cause is often a combination of predisposing factors (advanced age, cognitive impairment) and precipitating factors (medications, acute illness).
From the Research
Delirium Workup in an 89-Year-Old Patient
The appropriate workup for delirium in an elderly patient without specific symptoms involves a comprehensive approach, including:
- Clinical history: A careful history is essential to identify predisposing and precipitating factors, such as medications, infections, and electrolyte disturbances 2, 3.
- Physical examination: A thorough physical examination is necessary to identify any underlying medical conditions that may be contributing to delirium 2, 3.
- Laboratory testing: Laboratory tests, such as complete blood count, electrolyte panel, and liver function tests, may be ordered to rule out underlying medical conditions 2, 3.
- Medication review: A review of the patient's medication list is crucial, as medications with anticholinergic potential are a common reversible cause of delirium 2, 3.
- Screening for delirium: The use of validated delirium instruments, such as the Confusion Assessment Method, is recommended to screen for delirium 4, 5.
Risk Factors and Prevention
Elderly patients with multiple comorbidities, recent surgery, and polypharmacy are at increased risk of developing delirium 6, 5. Preventive interventions, such as:
- Frequent reorientation
- Early and recurrent mobilization
- Pain management
- Adequate nutrition and hydration
- Reducing sensory impairments
- Ensuring proper sleep patterns can help reduce the incidence of delirium 6, 4.
Management
The management of delirium involves identifying and managing the underlying medical conditions, providing supportive care, and preventing complications 2, 6. Pharmacologic interventions should be reserved for patients who are a threat to their own safety or the safety of others, and those nearing death 6, 4. The use of antipsychotics and other psychoactive medications should be avoided, as they do not reliably improve brain function in critically ill delirious patients 4.