What is the recommended management for delirium in geriatric patients?

Management of Delirium in Geriatric Patients

Implement multicomponent nonpharmacological interventions as first-line management for delirium in geriatric patients, while simultaneously identifying and treating underlying causes; reserve antipsychotics only for severe agitation that poses imminent safety risks, using the lowest effective dose for the shortest duration. 1, 2

Immediate Assessment and Diagnosis

• Use validated screening tools to diagnose delirium: the Confusion Assessment Method (CAM), Brief Confusion Assessment Method (b-CAM), or the 3-Minute Diagnostic Assessment (3D-CAM) 3, 1, 4
• Distinguish delirium from dementia by identifying acute onset, fluctuating course, impaired attention, and disordered consciousness—features that are generally preserved in dementia except in advanced stages 3
• Recognize that hypoactive delirium is more common in older adults and carries greater morbidity and mortality, yet is frequently missed because patients appear quiet rather than agitated 1, 2

Identify and Treat Underlying Causes

Promptly perform a comprehensive medical evaluation with appropriate diagnostic tests to identify all contributing factors, as delays in treatment prolong delirium and worsen cognitive and functional recovery. 3, 1

Most Common Precipitants to Investigate:

• Infections: Urinary tract infections and pneumonia are the most frequent infectious causes 3, 1
• Medications: Anticholinergic medications, benzodiazepines, and sedative-hypnotics are the highest-risk culprits 3, 1, 5
• Metabolic disturbances: Dehydration, electrolyte abnormalities 3
• Hypoxia: Inadequate oxygen delivery from cardiac, pulmonary, or hematologic causes 3
• Pain: Inadequate analgesia 3
• Urinary retention and constipation: Bowel/bladder dysfunction 3

Nonpharmacological Interventions (First-Line Treatment)

These interventions can reduce delirium incidence by 40% and should be implemented immediately for all patients. 4, 6

Core Multicomponent Interventions:

• Mobility and exercise: Implement early mobilization and physical therapy to shorten delirium duration 1, 3
• Reorientation: Frequently reassure and reorient the patient; use visible calendars, clocks, and caregiver identification; explain all activities clearly 3, 1
• Sensory optimization: Provide glasses and hearing aids to minimize sensory deprivation 3, 1
• Sleep enhancement: Regulate sleep-wake cycles, minimize nighttime disruptions 1, 3
• Nutrition and hydration: Ensure adequate intake and promptly treat dehydration 3, 1
• Therapeutic activities: Provide appropriate sensory stimulation 3
• Oxygen optimization: Maximize oxygen delivery with supplemental oxygen, blood products, and blood pressure support as needed 3

Environmental Modifications:

• Eliminate or minimize identified risk factors 3
• Increase awareness and vision whenever possible 3
• Foster a therapeutic environment that improves safety and decreases injury likelihood 3

Pharmacological Management

Avoid conventional antipsychotics (haloperidol) or atypical antipsychotics for routine delirium prevention or treatment, as evidence supporting their use is limited and they show no clear benefit in clinically significant outcomes. 1, 2

When Pharmacotherapy Is Necessary:

• Reserve antipsychotics exclusively for severe agitation, psychosis, or distress that poses imminent risk to patient or staff safety or threatens interruption of essential medical therapies 1, 2, 6
• Use the lowest effective dose for the shortest possible duration 1, 5, 6
• When chemical restraint is absolutely necessary, haloperidol is recommended over lorazepam for acute treatment 3

Preferred Agent for Geriatric Patients (When Antipsychotic Required):

• Quetiapine has the lowest risk of extrapyramidal symptoms (EPS) among commonly used antipsychotics 5
• Start at 25mg orally every 12 hours if scheduled dosing is required 5
• Monitor for orthostatic hypotension, especially during initial titration 5
• Avoid combining with benzodiazepines due to increased sedation risk 5

Alternative Agents:

• Dexmedetomidine may be considered for hyperactive delirium in mechanically ventilated and non-intubated patients when nonpharmacological approaches fail 1

Critical Pitfalls to Avoid

• Never use physical restraints to manage behavioral symptoms, as they may exacerbate delirium 3, 1
• Do not delay treatment of underlying causes, as this prolongs delirium and worsens cognitive outcomes 3, 1
• Avoid attributing symptoms solely to dementia without investigating for acute reversible causes 1
• Do not overlook polypharmacy; perform medication reconciliation and discontinue high-risk medications 1
• Minimize chemical restraint/sedation whenever possible 3

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 1
• Provide education to nursing staff and healthcare providers about delirium recognition and management 1
• Conduct daily in-person evaluations when using any antipsychotic 5

Monitoring and Follow-Up

• Reevaluate delirium screening regularly, as mental status changes may wax and wane 3
• Use severity measures such as the CAM-Severity Score to monitor response to treatment and assess prognosis 6
• Arrange follow-up with primary care providers on discharge for ongoing screening of cognitive impairment 4