What are the management strategies for mental changes, such as delirium and cognitive decline, in the geriatric population after an acute infection?

Management Strategies for Mental Changes in Geriatric Patients After Acute Infection

Multicomponent non-pharmacological interventions implemented by an interdisciplinary team should be the first-line approach for managing delirium and cognitive decline in geriatric patients following acute infection. 1

Diagnosis and Assessment

Identifying Delirium

• Use validated screening tools such as the Confusion Assessment Method (CAM) to diagnose delirium, which is characterized by acute onset, fluctuating course, inattention, and disorganized thinking 1, 2
• Differentiate between hyperactive, hypoactive, and mixed delirium subtypes, noting that hypoactive delirium is more common in older adults and associated with greater morbidity and mortality 1
• Recognize that delirium superimposed on dementia is associated with worse cognitive outcomes, with studies showing a 3-point decline in Montreal Cognitive Assessment (MoCA) scores at 1-year follow-up 3

Post-Infection Cognitive Assessment

• Perform cognitive assessment using standardized tools like MoCA or Mini-Mental State Examination to establish baseline and monitor changes 3
• Understand that infections are major precipitants of delirium and can accelerate neurodegenerative processes in vulnerable older adults 3, 4
• Monitor for cognitive changes even after apparent resolution of infection, as delirium should be considered a marker for future cognitive and functional decline 5

Management Approach

Identify and Treat Underlying Causes

• Promptly evaluate and treat the underlying infection to prevent prolonged delirium, which is associated with worse cognitive and functional recovery 1
• Perform a comprehensive medical evaluation including appropriate diagnostic tests to identify and manage all contributing factors to delirium 1
• Make medication adjustments to eliminate potentially deliriogenic drugs, particularly anticholinergics, benzodiazepines, and sedative-hypnotics 2, 6

Multicomponent Non-Pharmacological Interventions

• Implement interventions including mobility/exercise/physical therapy, reorientation, therapeutic activities, nutrition and hydration maintenance, and sleep enhancement 1
• Ensure proper vision and hearing adaptation by providing glasses and hearing aids to minimize sensory deprivation 1
• Maintain adequate oxygenation, manage pain appropriately, and prevent constipation 1, 6

Pharmacological Management

• Avoid conventional antipsychotics like haloperidol or atypical antipsychotics (olanzapine, quetiapine, ziprasidone) for delirium prevention or treatment as evidence supporting their use is limited 1
• Consider dexmedetomidine for hyperactive delirium resolution in mechanically ventilated and non-intubated patients when non-pharmacological approaches fail 1
• Use short-acting agents (e.g., propofol and dexmedetomidine) over benzodiazepines in mechanically ventilated patients if sedation is required 1

Interdisciplinary Team Approach

• Engage an interdisciplinary team to perform daily rounds providing both general and specific recommendations 1
• Include geriatric consultation as part of multicomponent interventions to improve outcomes 1
• Provide education to nursing staff and other healthcare providers about delirium recognition and management 1

Prevention of Long-Term Cognitive Decline

• Implement early mobility and physical rehabilitation to potentially shorten delirium duration and reduce cognitive decline 1
• Monitor cognitive function during follow-up visits at 3 months, 1 year, and 3 years after acute infection to detect and address persistent or progressive cognitive impairment 4
• Consider the pathophysiological interaction between neurodegenerative changes, acute infection, and delirium when developing long-term management plans 3

Common Pitfalls to Avoid

• Avoid attributing symptoms solely to dementia without investigating for acute causes of delirium 2
• Prevent the use of physical restraints to manage behavioral symptoms, as they may exacerbate delirium 1
• Avoid overlooking the impact of polypharmacy and failure to perform medication reconciliation 2, 6
• Do not delay treatment of underlying causes, as this can prolong delirium and worsen cognitive outcomes 1

Special Considerations

• Recognize that urinary tract infections and pneumonia are the most common infectious causes of delirium in older adults 2
• Be aware that patients with pre-existing dementia who develop delirium during acute infection are at highest risk for accelerated cognitive decline 3
• Consider specialized hospital units for the inpatient care of older adults with delirium, although evidence for their benefit is currently insufficient 1