What is the best approach to manage delirium in an elderly male?

Management of Delirium in an Elderly Male

Immediately perform a comprehensive medical evaluation to identify and treat underlying causes while simultaneously implementing multicomponent non-pharmacological interventions delivered by an interdisciplinary team—this is the cornerstone of delirium management and must precede any consideration of pharmacological treatment. 1

Step 1: Urgent Medical Evaluation and Treatment of Underlying Causes

The first priority is identifying reversible contributors, as delayed treatment prolongs delirium and increases morbidity and mortality 1, 2:

Medication Review (Most Common Reversible Cause)

• Discontinue all anticholinergic medications immediately, including antihistamines like diphenhydramine and cyclizine 1, 2, 3
• Stop benzodiazepines unless treating alcohol or benzodiazepine withdrawal—these are potent precipitants of delirium 1, 2, 3
• Reduce opioids to minimum necessary doses, especially in patients with renal impairment where metabolites accumulate 2, 3
• Review polypharmacy burden and discontinue non-essential medications 1

Infection Assessment

• Urinary tract infections and pneumonia are the most common infectious causes—over 80% of patients with bacteremia show neurological symptoms 2, 4
• Critical pitfall: Only treat UTI if patient meets systemic sepsis criteria; treating asymptomatic bacteriuria worsens functional recovery and increases C. difficile infections 2

Metabolic and Electrolyte Evaluation

• Check for hypoxia, hypoglycemia, dehydration, and electrolyte imbalances 2, 4
• Suspect hypercalcemia even with subtle symptoms (confusion, drowsiness)—delirium is reversible in 40% of cases 2, 4
• Evaluate for hyponatremia due to SIADH 2, 4

Physical Examination for Often-Missed Causes

• Assess for pain systematically—unrecognized pain is a major contributor in elderly patients who cannot verbally communicate discomfort 1, 2
• Check for urinary retention, constipation, and pressure injuries 2, 4

Step 2: Multicomponent Non-Pharmacological Interventions (First-Line Treatment)

These interventions should be implemented immediately by an interdisciplinary team and can reduce delirium duration and severity 1:

Reorientation and Cognitive Support

• Provide frequent verbal reorientation to time, place, and person 1, 2
• Use calm tones, simple one-step commands, and allow adequate processing time 5

Sensory Optimization

• Ensure patient has glasses and hearing aids in place and functioning—visual and hearing impairments significantly contribute to delirium 1, 2, 4

Early Mobilization

• Implement active range-of-motion exercises and early mobilization protocols 1, 2

Sleep Hygiene

• Avoid nursing procedures during sleep hours, schedule medications to minimize sleep disruption, and reduce noise 1, 2
• Sleep deprivation is both a symptom and perpetuating factor 2, 4

Nutrition and Hydration

• Ensure adequate hydration and nutrition; check that dentures fit properly 1, 2

Pain Management

• Optimize pain control preferably with non-opioid medications 1

Environmental Safety

• Avoid physical restraints—they exacerbate delirium 1, 2
• Provide adequate lighting and reduce environmental confusion 1, 5

Step 3: Pharmacological Management (Restricted to Specific Situations Only)

Medications should only be used when the patient is severely agitated, threatening substantial harm to self or others, and behavioral interventions have failed or are impossible. 1, 5, 2

When to Consider Antipsychotics

Reserve for patients who are:

• Severely agitated or distressed 1, 5
• Threatening substantial harm to self or others 1, 5
• Experiencing distressing psychotic symptoms 1, 5

Medication Selection and Dosing

• Haloperidol 0.5-1 mg orally or subcutaneously is first-line for acute severe agitation 5, 6
• Risperidone 0.25-0.5 mg is an alternative option 5
• Use the lowest effective dose for the shortest possible duration 1, 5
• Evaluate daily with in-person examination and discontinue as soon as acute symptoms resolve 1, 5, 2

Critical Safety Discussion Required

Before initiating any antipsychotic, discuss with patient (if feasible) and surrogate decision maker 5:

• Increased mortality risk (1.6-1.7 times higher than placebo) 5
• Cardiovascular effects including QT prolongation and sudden death 1, 5
• Risk of falls, pneumonia, and metabolic effects 5

What NOT to Use

• Benzodiazepines should not be used as first-line treatment for agitation in delirium (except for alcohol/benzodiazepine withdrawal)—they increase delirium incidence and duration and cause paradoxical agitation in 10% of elderly patients 1, 5, 6
• Cholinesterase inhibitors should not be newly prescribed to prevent or treat delirium 1
• Avoid antipsychotics for hypoactive delirium 1

Step 4: Monitoring and Reassessment

• Use validated tools like the Confusion Assessment Method (CAM) for daily delirium assessment 2, 7
• Monitor for medication side effects including extrapyramidal symptoms, falls, and metabolic changes 5
• Taper and discontinue antipsychotics as soon as behavioral symptoms resolve—approximately 47% of patients continue receiving antipsychotics after discharge without clear indication 5

Common Pitfalls to Avoid

• Do not repeat neuroimaging unless new focal neurological findings develop—sedation or restraints required for imaging can worsen delirium 2, 4
• Do not empirically treat asymptomatic bacteriuria—this results in worse functional recovery 2
• Do not continue antipsychotics indefinitely—review need at every visit 5
• Patients over 75 years respond less well to antipsychotics, particularly olanzapine 5