What are the current clinical guidelines for managing delirium in the elderly?

Current Clinical Guidelines for Managing Delirium in the Elderly

Multicomponent nonpharmacologic interventions delivered by an interdisciplinary team are the cornerstone of both prevention and treatment of delirium in elderly patients, with medications reserved only for severe agitation threatening imminent harm to self or others. 1, 2

Prevention Strategies (Primary Intervention)

Strong evidence supports that multicomponent nonpharmacologic interventions can reduce delirium incidence by 40% and should be implemented for all at-risk older adults. 1, 3

Key prevention components include: 1, 2

• Reorientation protocols with frequent verbal orientation to time, place, and person
• Optimization of sensory function by ensuring patients have glasses and hearing aids in place
• Sleep hygiene with non-pharmacologic sleep protocols to address sleep deprivation
• Early mobilization to prevent functional decline
• Adequate nutrition and hydration
• Pain management preferably with nonopioid medications

Identification and Treatment of Underlying Causes (Highest Priority)

A comprehensive medical evaluation must be performed immediately after delirium diagnosis to identify and manage underlying contributors, as delayed treatment prolongs delirium and increases morbidity and mortality. 2

Critical underlying causes to investigate: 2

Infections:

• Bacteremia - Over 80% of patients with bacteremia have neurological symptoms ranging from lethargy to coma, yet may not show obvious laboratory abnormalities initially
• Urinary tract infection - Should be suspected and treated ONLY when patient meets systemic sepsis criteria; treating asymptomatic bacteriuria worsens functional recovery and increases Clostridium difficile infections
• Pneumonia - A common precipitant requiring systematic evaluation

Metabolic disturbances: 2

• Hypercalcemia - Should be suspected even with indolent symptoms; hypercalcemia-induced delirium is reversible in 40% of cases
• Hyponatremia due to SIADH may require specific testing beyond basic metabolic panel
• Hypoxia, hypoglycemia, and dehydration

Medication review (mandatory): 1, 2

• Discontinue all anticholinergics including antihistamines like cyclizine, diphenhydramine, hydroxyzine, cyclobenzaprine, oxybutynin, prochlorperazine, promethazine, tricyclic antidepressants, and paroxetine
• Discontinue benzodiazepines unless treating alcohol or benzodiazepine withdrawal, as they are strong precipitants of delirium
• Reduce opioids to minimum necessary doses, particularly in patients with renal impairment where metabolites can accumulate
• Avoid meperidine, histamine2-receptor antagonists (cimetidine), and sedative-hypnotics

Physical discomfort: 2

• Unrecognized pain is systematically undertreated in elderly patients with cognitive impairment
• Urinary retention and constipation
• Pressure injuries may cause pain-related delirium without obvious laboratory changes

Pharmacologic Management (Restricted Use Only)

What NOT to Use (Strong Recommendations)

Cholinesterase inhibitors should NOT be newly prescribed to prevent or treat postoperative delirium. 1

Benzodiazepines should NOT be used as first-line treatment of agitation associated with delirium (except for alcohol or benzodiazepine withdrawal). 1 Evidence shows benzodiazepines increase delirium incidence, prolong delirium duration, and cause paradoxical agitation in approximately 10% of elderly patients. 1

Antipsychotics and benzodiazepines should be avoided for treatment of hypoactive delirium. 1 Pharmacologic treatment has not been consistently shown to modify the duration or severity of delirium, and the harms are substantial with potential for increased morbidity and mortality. 1

When Antipsychotics May Be Considered (Weak Recommendation)

Antipsychotics (haloperidol, risperidone, olanzapine, quetiapine, or ziprasidone) may be used at the lowest effective dose for the shortest possible duration ONLY when patients are severely agitated or distressed or threatening substantial harm to self and/or others. 1, 2

Specific considerations: 1, 2

• Use only after behavioral interventions have failed or are not possible
• Evaluate ongoing use daily with in-person examination
• Patients over 75 years respond less well to antipsychotics, particularly olanzapine
• Short-term treatment is associated with increased mortality
• Discontinue immediately once acute distressing symptoms resolve

Potential harms include: 1

• QT prolongation, dysrhythmias, sudden death
• Hypotension and tachycardia
• Extrapyramidal effects, neuroleptic malignant syndrome
• Pneumonia, falls, deep venous thrombosis
• Metabolic effects (weight gain, insulin resistance)
• 47% of patients continue receiving antipsychotics after ICU discharge and 33% as outpatients without clear indication - this inadvertent chronic administration must be avoided

Pain Management

Pain should be optimized preferably with nonopioid medications to prevent postoperative delirium. 1 Regional anesthetic injection at the time of surgery and postoperatively may be considered to improve pain control with the goal of preventing delirium. 1

Healthcare Professional Education

Ongoing educational programs regarding delirium should be provided for healthcare professionals. 1 This addresses the critical problem that delirium remains undiagnosed in more than half of clinical cases, largely because hypoactive delirium is typically unrecognized or misattributed to dementia. 1

Critical Pitfalls to Avoid

• Do NOT treat asymptomatic bacteriuria empirically - this results in worse functional recovery and higher C. difficile infection rates 2
• Do NOT repeat neuroimaging unless new focal neurological findings develop - sedation or restraints required for imaging can worsen delirium 2
• Do NOT use physical restraints for managing behavioral symptoms - they exacerbate delirium 2
• Do NOT continue antipsychotics indefinitely - approximately 47% of patients inappropriately continue these medications after discharge without clear indication 1

Monitoring and Follow-Up

Daily evaluation of delirium using validated tools such as the Confusion Assessment Method (CAM) is recommended. 2, 3 The CAM and its variations (3D CAM, CAM-ICU, Brief CAM) are the most widely used clinical assessment tools for diagnosis. 3