What is the recommended evaluation and treatment for acute delirium in an older adult (>65 years) with possible dementia, recent surgery, infection, metabolic disturbance, medication changes, or substance withdrawal?

Acute Delirium: Evaluation and Treatment

The cornerstone of managing acute delirium in older adults is identifying and reversing precipitating causes through systematic evaluation, followed by multicomponent nonpharmacological interventions—antipsychotics should NOT be routinely used and are reserved only for severe agitation threatening patient or staff safety. 1, 2

Initial Evaluation: Systematic Search for Reversible Causes

The evaluation must focus on identifying modifiable precipitating factors through a structured approach:

Medication Review (First Priority)

• Immediately review and discontinue or reduce anticholinergic medications, benzodiazepines, and corticosteroids 2, 1
• Assess for polypharmacy and drug interactions, particularly in patients taking multiple medications 1, 3
• Consider opioid-related delirium and reduce or switch opioids if suspected 2

Infection Screening

• Screen specifically for urinary tract infections and pneumonia as these are the most common infectious precipitants 1, 2, 1
• Treat identified infections according to goals of care, though evidence shows infection-related delirium has lower reversibility rates than medication or metabolic causes 1
• Do NOT empirically treat asymptomatic bacteriuria with antibiotics—this worsens functional recovery and increases C. difficile risk 1

Metabolic and Physiologic Assessment

• Obtain complete blood count, comprehensive metabolic panel (electrolytes, glucose, calcium, BUN/creatinine), and medication levels where applicable 1
• Correct dehydration, electrolyte imbalances (particularly hyponatremia), hypoglycemia, and hypercalcemia 1, 2
• In cancer patients, hypercalcemia-induced delirium is often reversible (40% of episodes) with IV bisphosphonates (pamidronate or zoledronic acid) 1
• Assess and optimize oxygenation; treat hypoxia promptly 2, 4

Pain Assessment

• Evaluate for pain using both verbal and non-verbal cues (facial grimacing, moaning, resistance to care) 2
• Provide adequate analgesia, preferably with non-opioid medications when sufficient 2, 4

Other Reversible Factors

• Address constipation and urinary retention as these exacerbate behavioral symptoms 2
• Ensure hearing aids and eyeglasses are functioning and in use; remove earwax 2, 4
• Assess nutritional status and ensure dentures fit properly 2

Neuroimaging Considerations

Neuroimaging is NOT routinely indicated for delirium unless specific concerning features are present 1:

• Focal neurological deficits suggesting stroke
• Head trauma history
• Suspected intracranial mass, infection, or hemorrhage
• New seizure activity
• CT head without contrast is the initial imaging modality when indicated; MRI is reserved for suspected occult pathology when CT is unrevealing 1

Nonpharmacological Interventions (Primary Treatment)

These interventions should be maximized BEFORE considering any pharmacological treatment 1, 2, 4:

Environmental and Reorientation Strategies

• Provide frequent reorientation with simple, repetitive instructions 2, 4
• Place visible clocks, calendars, and family photos in the room 2, 4
• Ensure adequate lighting during daytime and maintain normal day-night cycles 2, 4
• Minimize room changes and assign consistent nursing staff 4

Sleep Hygiene

• Avoid nursing procedures and medication administration during sleeping hours 2, 4
• Reduce noise to minimum levels during sleep periods 2, 4
• Never use benzodiazepines as sleep aids—they cause and worsen delirium 1, 4

Mobilization

• Initiate early mobilization and physical therapy as soon as medically safe 2, 4
• For bedbound patients, perform active range-of-motion exercises 2

Physical Restraints

• Minimize or avoid physical restraints as they exacerbate delirium 1, 2
• Use only when absolutely necessary to prevent substantial harm 1

Pharmacological Treatment: When and What to Use

Strong Recommendation AGAINST Routine Antipsychotic Use

The 2018 Critical Care Medicine guidelines explicitly recommend AGAINST routinely using haloperidol, atypical antipsychotics, or statins to treat delirium 1. This represents the highest quality, most recent evidence for critically ill adults and should guide general practice.

Limited Indications for Antipsychotics

Antipsychotics may be considered ONLY for 1, 2:

• Severe agitation threatening substantial harm to self or others
• Moderate to severe hyperactive delirium causing significant distress

When used, employ the following approach 2:

• Haloperidol: Start 0.5-1 mg PO/IM, repeat hourly as needed
• Olanzapine: Start 2.5-5 mg PO/IM
• Quetiapine: Start 25 mg PO
• Risperidone: Start 0.5 mg PO
• Use the lowest effective dose for the shortest possible duration 1
• Titrate to optimal symptom relief while monitoring for side effects 2

Critical Safety Warning for Dementia Patients

All antipsychotics increase mortality risk by 1.6-1.7 times in elderly patients with dementia-related psychosis 2. Additional risks include cardiovascular effects, cerebrovascular events, falls, and metabolic changes 2. Document the risk-benefit discussion and rationale for use 2.

What NOT to Use

• Do NOT use benzodiazepines as first-line treatment for agitation associated with delirium 1
• Do NOT use antipsychotics or benzodiazepines for hypoactive delirium 1
• Do NOT newly prescribe cholinesterase inhibitors for delirium prevention or treatment 1

Postoperative Delirium Considerations

For older adults with recent surgery 1, 4:

• Regional anesthesia at the time of surgery and postoperatively may prevent delirium 1, 4
• Processed EEG monitoring during general anesthesia to avoid excessive anesthetic depth may be used 1, 4
• Multicomponent nonpharmacological interventions by an interdisciplinary team should be implemented throughout the perioperative period 1, 4

Common Pitfalls to Avoid

• Do NOT assume confusion is "just dementia"—always screen for superimposed delirium using validated tools (Confusion Assessment Method, Brief CAM, or Delirium Triage Screen) 1, 4, 5
• Do NOT treat asymptomatic bacteriuria empirically in delirious older adults 1
• Do NOT use antipsychotics prophylactically to prevent delirium 1
• Do NOT overlook substance withdrawal (alcohol, benzodiazepines) as a precipitating factor 1, 3
• Do NOT forget to reassess delirium status regularly as mental status changes wax and wane 1