What are the treatments for delirium in geriatric patients or those with significant medical histories?

Treatment of Delirium in Geriatric Patients

The most effective treatment for delirium is multicomponent nonpharmacological interventions delivered by an interdisciplinary team, combined with immediate identification and treatment of underlying medical causes—antipsychotics should NOT be used routinely to treat delirium itself, only for managing severe agitation, psychosis, or distress when nonpharmacological approaches fail. 1, 2, 3

Immediate Priority: Identify and Treat Underlying Causes

Perform a comprehensive medical evaluation immediately upon diagnosis, as delayed treatment prolongs delirium and increases morbidity and mortality. 1, 4

Most Common Reversible Causes to Address:

• Infections: Urinary tract infections and pneumonia are the most frequent infectious causes; over 80% of patients with bacteremia show neurological symptoms 4, 2
• Medications: Discontinue anticholinergics (including antihistamines like cyclizine), benzodiazepines (unless treating alcohol/sedative withdrawal), and review opioids especially in renal impairment 4, 2, 5
• Metabolic derangements: Check for dehydration, hypercalcemia (reversible in 40% of cases), hyponatremia from SIADH, and electrolyte imbalances 4
• Neurological causes: Consider cerebrovascular disease, subdural hematoma, seizures, or intracranial pathology 4, 2
• Often-overlooked factors: Pain, constipation, urinary retention, and pressure ulcers 4, 2

Multicomponent Nonpharmacological Interventions (First-Line Treatment)

Healthcare systems should implement multicomponent nonpharmacological programs delivered by an interdisciplinary team for the entire hospitalization. 1

Core Components to Implement:

• Cognitive reorientation: Frequent reorientation to time, place, and person 1, 2
• Early mobility/physical therapy: Initiate as soon as medically safe to potentially shorten delirium duration 1, 2
• Sensory optimization: Ensure patients use glasses and hearing aids; visual and hearing impairments significantly contribute to delirium 1, 4, 2
• Sleep enhancement: Implement nonpharmacologic sleep protocols and sleep hygiene measures, as sleep deprivation both causes and prolongs delirium 1, 4, 2
• Nutrition and hydration: Maintain adequate intake 1, 2
• Pain management: Address pain appropriately without over-reliance on opioids 1
• Environmental modifications: Reduce noise, maintain day-night cycles, minimize room changes 1

Critical caveat: Physical restraints should NOT be used to manage behavioral symptoms, as they worsen delirium 4, 2

Pharmacological Management (Only When Necessary)

When Antipsychotics May Be Considered:

Antipsychotics should be reserved for managing severe agitation, psychosis, or distress that poses safety risks and has not responded to nonpharmacological interventions—they are NOT a treatment for delirium itself and show no clear benefit in clinically significant outcomes. 2, 3

If Antipsychotic Use Is Unavoidable:

Use the lowest effective dose for the shortest possible duration. 2, 6, 3

Preferred Agent for Geriatric Patients:

• Quetiapine: Lowest risk of extrapyramidal symptoms (EPS) among antipsychotics; start at 25mg orally every 12 hours if scheduled dosing required 6
• Monitor for orthostatic hypotension during initial titration 6
• Avoid combining with benzodiazepines due to increased sedation risk 6

Alternative Agents (in order of increasing EPS risk):

• Aripiprazole: Start at 5mg; less likely to cause EPS but has more drug interactions 6
• Olanzapine: Start at 2.5-5mg; moderate EPS risk, may cause drowsiness and orthostatic hypotension 6
• Risperidone: Start at 0.25-0.5mg; increased EPS risk if dose exceeds 2mg, especially problematic at doses >6mg/24h 6

Haloperidol: While historically considered first-line, it has significant risks in elderly patients including QTc prolongation, EPS, and potential for severe neurotoxicity in thyrotoxicosis 7, 8, 9

Benzodiazepines:

Use ONLY for alcohol or sedative-hypnotic withdrawal-related delirium; otherwise, benzodiazepines are potent precipitants of delirium and should be discontinued. 4, 2, 9

Monitoring and Team Approach

• Daily evaluation with in-person examination when using any antipsychotic 6
• Interdisciplinary team should perform daily rounds providing specific recommendations 1, 2
• Include geriatric consultation as part of multicomponent interventions 1, 2
• Monitor complete blood count if using antipsychotics, as leukopenia/neutropenia can occur; discontinue if severe neutropenia develops (ANC <1000/mm³) 7, 8

Common Pitfalls to Avoid

• Do not attribute symptoms solely to dementia without investigating acute causes 2
• Do not delay treatment of underlying causes, as this worsens cognitive outcomes 1, 2
• Do not use antipsychotics for prevention of delirium—evidence does not support this practice 2, 3
• Do not overlook polypharmacy; perform medication reconciliation 2
• Avoid typical antipsychotics when possible due to high risk of severe side effects and up to 50% risk of irreversible tardive dyskinesia after 2 years of continuous use 6

Evidence Quality Note

The strongest evidence (moderate quality) supports multicomponent nonpharmacological interventions for both prevention and management of delirium, with 10 studies showing consistent benefit 1. In contrast, pharmacological interventions lack unanimous evidence of effectiveness for either prevention or treatment 3, 10.