What is the recommended assessment and management plan for acute delirium in an older hospitalized patient with pre‑existing dementia, recent surgery, possible infection, metabolic disturbances, and exposure to multiple high‑risk medications?

Assessment and Management of Acute Delirium in Hospitalized Older Adults with Dementia

Immediately implement a two-step delirium screening using the Delirium Triage Screen followed by the Brief Confusion Assessment Method (bCAM), then systematically address reversible causes—prioritizing medication review, infection workup, metabolic correction, pain control, and environmental optimization—while reserving antipsychotics only for severe agitation threatening substantial harm after non-pharmacological interventions have failed. 1, 2

Immediate Diagnostic Assessment

Step 1: Confirm Delirium Diagnosis

• Use the two-step validated screening process: Start with the highly sensitive Delirium Triage Screen, then confirm with the highly specific Brief Confusion Assessment Method (bCAM). 1, 2
• Repeat screening regularly throughout hospitalization because delirium symptoms fluctuate and can develop at any point during the hospital stay. 1, 2
• Distinguish from baseline dementia by identifying acute onset (hours to days), fluctuating course, disordered attention, and altered consciousness—features that differ from the insidious, constant pattern of dementia alone. 1

Step 2: Systematic Evaluation of Reversible Causes

The American Geriatrics Society emphasizes that comprehensive medical evaluation must occur immediately after diagnosis, as delayed treatment prolongs delirium and increases mortality. 2

Medication Review (Priority #1)

• Conduct a complete medication audit focusing on recent additions, dose changes, and cumulative anticholinergic burden—medications account for up to 64% of delirium cases in hospitalized patients without infection. 3
• Immediately discontinue or reduce:
  • Benzodiazepines (potent delirium precipitants unless treating alcohol/benzodiazepine withdrawal) 3, 2
  • Anticholinergic medications including antihistamines like cyclizine 3, 2
  • Opioids, especially in renal insufficiency where metabolites accumulate 3, 2
  • Corticosteroids at high doses 3

Infection Workup (Priority #2)

• Evaluate for urinary tract infection and pneumonia—the most common infectious causes in geriatric delirium. 1, 2
• Critical pitfall: Do NOT treat asymptomatic bacteriuria in elderly delirious patients; treatment is associated with worse functional recovery and increased Clostridioides difficile risk without improving delirium resolution. 3
• Consider bacteremia, which causes neurological symptoms ranging from lethargy to coma in over 80% of cases. 2

Metabolic and Electrolyte Assessment (Priority #3)

• Order comprehensive metabolic panel including electrolytes, glucose, calcium, renal function (BUN/creatinine), hepatic function, and albumin—metabolic derangements are present in 46% of hospitalized delirious patients. 3, 2
• Specifically evaluate:
  • Hyponatremia and hypernatremia 3
  • Hypercalcemia (suspect even with subtle symptoms like confusion or somnolence; reversible in 40% of cases) 2
  • Glucose abnormalities 3
  • Elevated BUN/creatinine ratio indicating dehydration 3
• Assess hydration status clinically, as dehydration may not be apparent on initial labs. 2

Oxygenation and Organ Function

• Measure oxygen saturation and provide supplemental oxygen if needed; hypoxia is a reversible cause requiring prompt correction. 4, 2
• Evaluate for respiratory failure, cardiac arrhythmias, and end-stage organ disease (heart, kidney, liver) that create baseline vulnerability. 3

Often-Overlooked Physical Causes

• Perform thorough physical examination for:
  • Pain assessment using validated tools (PAINAD for non-verbal patients, numeric rating scale for verbal patients)—untreated pain both precipitates and perpetuates delirium. 3, 4, 2
  • Constipation and urinary retention—frequently missed reversible triggers. 3, 4, 2
  • Pressure ulcers and dental problems 4

Sensory and Environmental Factors

• Ensure patients use glasses and hearing aids—visual and hearing impairments significantly contribute to delirium. 2
• Assess sleep-wake cycle disruption—sleep deprivation both symptoms and prolongs delirium. 3, 2

Neurological Causes (When Indicated)

• Consider cerebrovascular events, subdural hematoma, seizures, or CNS infection if focal neurological signs present or if delirium persists despite addressing common causes. 2

Non-Pharmacological Management (First-Line for All Patients)

The American Geriatrics Society provides a strong recommendation for multicomponent non-pharmacological interventions as primary treatment, with essentially no risk of harm. 1, 2

Core Intervention Bundle

• Cognitive reorientation: Frequently reassure and reorient patient to person, place, time using simple, clear instructions with visual cues (calendars, clocks, caregiver identification). 1, 2
• Sleep enhancement: Implement non-pharmacological sleep protocols—quiet room, adequate lighting, noise-reduction strategies, minimize nighttime interruptions for vital signs. 1, 3
• Early mobilization: Increase supervised mobility with physical therapy in short sessions distributed throughout the day to prevent fatigue. 1, 2
• Pain management: Prioritize non-opioid analgesics (scheduled acetaminophen) to minimize sedation and fall risk. 1, 2
• Sensory optimization: Provide adequate light, reduce noise, ensure sensory aids (glasses, hearing aids) are available and functioning. 1, 2
• Foster familiarity: Encourage family/friends at bedside, bring familiar objects from home, maintain consistency of caregivers, minimize room relocations. 1
• Nutrition and hydration: Ensure adequate intake and correct dehydration. 1
• Bowel/bladder regulation: Prevent and treat constipation and urinary retention; remove urinary catheters when possible. 1, 3

Implementation Strategy

• Deploy interdisciplinary team including physicians, nurses, physical therapists, occupational therapists, and social workers. 1, 2
• Provide formal education to all healthcare professionals on delirium recognition, screening tools, risk factors, and management approaches with ongoing refresher sessions. 1, 2

Pharmacological Management (Reserved for Specific Situations)

When to Consider Antipsychotics

Antipsychotics should be reserved ONLY for patients who are severely agitated, threatening substantial harm to themselves or others, or when non-pharmacological approaches have been attempted and failed. 1, 2

• Use the lowest effective dose for the shortest duration possible. 2
• Haloperidol is recommended over lorazepam for acute treatment when chemical intervention is necessary. 1
• Newer antipsychotics (e.g., quetiapine, olanzapine) may be considered as they have faster onset and fewer adverse effects than haloperidol. 5
• NEVER use antipsychotics for hypoactive delirium—reserve only for severe agitation. 2
• AVOID benzodiazepines except for alcohol or benzodiazepine withdrawal, as they worsen delirium. 3, 2

Critical Safety Measures

• Minimize physical restraints—they worsen delirium and should be used only when absolutely necessary for safety. 1, 2
• Never initiate antipsychotics without first ruling out and treating pain, infection, constipation, urinary retention, and medication side effects. 4

Special Considerations for Post-Surgical Patients

• Postoperative delirium requires the same systematic approach with particular attention to opioid-related delirium in the setting of pain management. 1, 3
• Balance pain control with delirium risk: Untreated pain precipitates delirium, but opioids can also cause it—prioritize multimodal analgesia with non-opioid agents when possible. 3

Prognosis and Follow-Up

• Delirium is a medical emergency with mortality rates twice as high when diagnosis is missed; overall mortality in altered mental status is approximately 8.1% and significantly higher in elderly patients. 2
• Patients with prolonged delirium have approximately three times the risk of dying within one year compared to those with quick resolution, emphasizing the importance of prevention and early detection. 5
• Multiple simultaneous causes are present in 69% of cases (median of three probable causes), requiring comprehensive evaluation rather than stopping at the first identified factor. 3