What is the best strategy for managing hospital-acquired delirium in an elderly patient?

Managing Hospital-Acquired Delirium in Elderly Patients

Multicomponent non-pharmacological interventions delivered by an interdisciplinary team should be the first-line approach for both prevention and management of hospital-acquired delirium in elderly patients. 1, 2

Screening and Assessment

• Use validated screening tools such as the Confusion Assessment Method (CAM) or 4 'A's Test (4AT) to identify delirium 2
• Screen at-risk elderly patients upon admission and continue screening twice daily until day 5 or discharge 2
• Perform a medical evaluation to identify and manage underlying contributors to delirium, including:
  • Medication review (especially high-risk medications)
  • Laboratory tests to identify metabolic abnormalities
  • Assessment for dehydration and malnutrition 1, 2

Core Non-Pharmacological Interventions

Orientation Strategies

• Frequent reorientation to time, place, and person
• Provide visible clocks, calendars, and familiar objects from home
• Clear communication with patients 2

Sensory Optimization

• Ensure hearing aids and glasses are available and used
• Provide adequate lighting during day and reduce at night
• Minimize noise 1, 2

Mobility and Function

• Implement early and frequent mobilization
• Engage physical therapy when appropriate
• Avoid physical restraints (which can worsen delirium) 1, 2, 3

Sleep-Wake Cycle Management

• Provide dark, quiet rooms at night
• Schedule care activities to minimize sleep disruption
• Implement non-pharmacological sleep protocols 1, 2

Nutrition and Hydration

• Ensure adequate nutrition and hydration (dehydration is a common precipitating factor)
• Provide assistance with meals if needed
• Consider nutritional supplements for malnourished patients 1, 2

Pain Management

• Optimize pain control using minimally sedating multimodal approaches
• Titrate opioids to minimal effective dose
• Consider non-opioid alternatives when possible 1, 2

Family Involvement

• Encourage presence of family and friends
• Educate family members to assist with reorientation and care 2

Medication Management

• Review and minimize use of high-risk medications:
  • Benzodiazepines (should not be used as first-line treatment for agitation)
  • Anticholinergics
  • Opioids (when possible)
  • Sedatives 1, 2
• Avoid newly prescribing cholinesterase inhibitors to treat delirium 1
• Avoid antipsychotics and benzodiazepines for hypoactive delirium 1

Pharmacological Interventions

• Reserve pharmacological therapy only for patients who pose a safety risk to themselves or others 2
• If needed, consider antipsychotics (haloperidol, risperidone, olanzapine, quetiapine, or ziprasidone) at the lowest effective dose for the shortest possible duration 1
• Have a clear tapering plan for any antipsychotic prescribed 3

Implementation Strategies

• Implement an interdisciplinary team approach involving physicians, nurses, physical therapists, and nutritional services 1, 2
• Provide staff education on delirium prevention, recognition, and management 1, 2
• Use checklists to promote adherence to non-pharmacological interventions 2
• Minimize unnecessary transfers between hospital units 2

Effectiveness and Outcomes

• Multicomponent non-pharmacological interventions can reduce delirium incidence by up to 40% 3, 4
• These interventions have been shown to improve outcomes related to:
  • Mortality
  • Length of hospital stay
  • Functional decline
  • Institutionalization 2, 4

Common Pitfalls to Avoid

• Failing to recognize hypoactive delirium (withdrawn, decreased motor activity), which is often missed or misattributed to dementia 1
• Using physical restraints, which can worsen delirium 1
• Relying on pharmacological interventions as first-line treatment 1, 2
• Inadequate screening, especially in patients with pre-existing cognitive impairment 1
• Overlooking dehydration and malnutrition as common precipitating factors 1, 2

The evidence strongly supports that a systematic, multicomponent approach addressing modifiable risk factors is the most effective strategy for both preventing and managing hospital-acquired delirium in elderly patients, with pharmacological interventions reserved only for cases where patient safety is at immediate risk.