What is the full inpatient management plan for an elderly patient presenting with confusion?

Comprehensive Management of Confusion in Elderly Inpatients

The management of confusion in elderly inpatients requires prompt identification of underlying causes, implementation of non-pharmacological interventions, and judicious use of medications only when necessary, with the primary goal of reducing morbidity and mortality. 1

Initial Assessment and Diagnosis

Differentiate Delirium from Dementia

Feature	Delirium	Dementia
Onset	Acute	Insidious
Course	Fluctuating	Constant
Attention	Disordered	Generally Preserved*
Consciousness	Disordered	Generally Preserved*
Hallucinations	Often Present	Generally Absent*

*Variable in Advanced Dementia 1

Screening Tools

• Use validated screening tools:
  • Confusion Assessment Method (CAM)
  • Brief Confusion Assessment Method
  • Delirium Triage Screen 2

Identify Underlying Causes

Perform targeted evaluation for common causes:

1. Infections

   • Urinary tract infection
   • Pneumonia
   • Sepsis

2. Metabolic Disturbances

   • Electrolyte abnormalities (sodium, calcium, magnesium)
   • Dehydration
   • Renal failure
   • Liver dysfunction
   • Hypoglycemia/hyperglycemia

3. Medication-Related

   • Review all medications, especially:
     • Anticholinergics
     • Sedatives/hypnotics
     • Opioids
     • Antipsychotics
     • Diuretics 1

4. Cardiovascular Issues

   • Congestive heart failure
   • Myocardial infarction
   • Pulmonary embolism 3
   • Hypotension/orthostatic hypotension

5. Neurological Disorders

   • Stroke/TIA
   • Subdural hematoma
   • Seizures

6. Hypoxia

   • Check oxygen saturation
   • Consider arterial blood gas analysis 3

7. Pain

   • Undertreated pain can cause confusion

8. Sensory Impairment

   • Visual or hearing deficits

Non-Pharmacological Management

Implement these interventions immediately while investigating causes:

1. Reorientation Strategies

   • Provide frequent information about time, place, and situation
   • Use orientation boards, visible clocks, and calendars
   • Ensure consistent communication 2

2. Environmental Modifications

   • Maintain environmental stability
   • Minimize transfers between rooms/units
   • Keep care teams consistent
   • Reduce noise and excessive stimulation
   • Ensure appropriate lighting (bright during day, dim at night) 2

3. Sensory Support

   • Ensure access to glasses and hearing aids
   • Check for impacted cerumen 2

4. Early Mobilization

   • Encourage activity and mobility as tolerated
   • Avoid unnecessary bed rest
   • Provide walking aids when needed
   • Avoid unnecessary urinary catheterization 2

5. Sleep-Wake Cycle Regulation

   • Increase exposure to daylight
   • Discourage daytime naps
   • Implement nighttime protocols to facilitate sleep
   • Reduce nighttime disruptions 2

6. Family Involvement

   • Educate family about delirium
   • Encourage family presence to help with reorientation
   • Obtain information about patient's baseline status 2

Pharmacological Management

Use medications only when non-pharmacological measures are insufficient and the patient presents severe symptoms that pose a risk to their safety. 2

First-Line Agents (for severe agitation/distress only)

• Atypical Antipsychotics:
  • Olanzapine: 2.5-5 mg PO/SC
  • Quetiapine: 25 mg immediate release
  • Aripiprazole: 5 mg PO/IM 2

Important Medication Considerations

• Start with low doses and titrate slowly
• Monitor for side effects, especially extrapyramidal symptoms
• Avoid haloperidol and risperidone in mild-to-moderate delirium as they can worsen symptoms 2
• Avoid benzodiazepines except for alcohol/benzodiazepine withdrawal delirium 2
• Avoid antipsychotics in patients with Parkinson's Disease or Lewy Body Dementia due to increased sensitivity 4
• Elderly patients with dementia-related psychosis treated with antipsychotics have increased mortality risk 4

Specific Management Based on Etiology

Infection

• Appropriate antibiotics based on culture results
• Ensure adequate hydration
• Monitor temperature and vital signs 1

Metabolic Disturbances

• Correct electrolyte imbalances
• Manage fluid status
• Monitor renal and liver function 1

Medication-Related

• Review all medications
• Discontinue or reduce doses of high-risk medications
• Consider medication reconciliation 1

Hypoxia

• Supplemental oxygen if needed
• Treat underlying cause (e.g., pulmonary embolism, pneumonia) 3

Cardiovascular Issues

• Optimize cardiac function
• Manage heart failure appropriately
• Monitor orthostatic vital signs 1

Pain Management

• Provide adequate pain control
• Use scheduled acetaminophen when appropriate
• Minimize opioid use when possible 2

Monitoring and Follow-Up

1. Regular Reassessment

   • Reassess mental status frequently
   • Monitor vital signs and oxygen saturation
   • Track response to interventions 1

2. Prevent Complications

   • Prevent falls (bed alarms, low beds, supervision)
   • Prevent pressure ulcers (frequent repositioning)
   • Maintain nutrition and hydration
   • Prevent aspiration 1, 2

3. Adjust Diabetes Management

   • Consider relaxing glycemic targets
   • Avoid sulfonylureas and short-acting insulin due to hypoglycemia risk
   • Monitor for hypoglycemia which can worsen confusion 1

Discharge Planning

1. Medication Review

   • Simplify medication regimen
   • Discontinue unnecessary medications
   • Provide clear medication instructions 1

2. Follow-Up

   • Arrange appropriate follow-up appointments
   • Consider cognitive assessment after resolution of delirium
   • Educate patient and family about risk factors for recurrence 1

3. Communication

   • Clearly communicate the discharge plan to the patient, family, and outpatient providers
   • Document episode of delirium in medical record 1

Common Pitfalls to Avoid

1. Underrecognition of hypoactive delirium - Be vigilant for quiet, withdrawn patients 2

2. Overreliance on medications - Non-pharmacological interventions should be first-line 2

3. Failure to address reversible causes - Always search for and treat underlying causes 2

4. Inappropriate use of physical restraints - These can worsen delirium 1

5. Assuming confusion is "normal aging" - Acute confusion always warrants investigation 1

6. Overlooking medication side effects - Particularly anticholinergics and sedatives 1

7. Inadequate pain management - Untreated pain can cause or worsen delirium 2

8. Ignoring the risk of refeeding syndrome - Can cause acute psychotic changes and delirium in malnourished elderly 1