How should acute delirium be evaluated and managed in an older hospitalized adult?

Evaluation and Management of Acute Delirium in Hospitalized Older Adults

Immediately screen every hospitalized older adult for delirium using a two-step validated approach: first the Delirium Triage Screen (highly sensitive), then confirm with the Brief Confusion Assessment Method (highly specific), and repeat this screening regularly throughout hospitalization since mental status fluctuates. 1, 2, 3

Diagnostic Approach

Use the CAM criteria to diagnose delirium: acute onset with fluctuating course, inattention, plus either disorganized thinking or altered consciousness. 1, 2 Distinguish this from dementia, which has insidious onset, constant course, and generally preserved attention and consciousness (except in advanced stages). 1

• Identify the delirium subtype (hyperactive, hypoactive, or mixed), recognizing that hypoactive delirium is more common in older adults and carries higher morbidity and mortality. 2, 3
• Never attribute confusion solely to pre-existing dementia without investigating acute precipitants—this is a critical diagnostic pitfall. 2, 3

Immediate Comprehensive Medical Evaluation

Perform an urgent systematic evaluation to identify all reversible causes, as delayed treatment prolongs delirium and increases mortality. 2, 3

Priority Infectious Causes

• Screen for urinary tract infection and pneumonia—these are the most common infectious triggers, with over 80% of bacteremic patients showing neurological symptoms. 2, 3
• Check for other occult infections (skin, intra-abdominal). 1

Medication Review (Anticholinergic Burden)

• Immediately discontinue anticholinergic medications (antihistamines like cyclizine, tricyclic antidepressants, bladder antimuscarinics). 1, 2, 3
• Stop benzodiazepines unless treating alcohol or benzodiazepine withdrawal—they are potent delirium precipitants. 1, 2, 3
• Review opioids, especially in renal impairment where metabolites accumulate. 3
• Perform complete medication reconciliation to address polypharmacy. 2

Metabolic and Electrolyte Assessment

• Check for dehydration (may not be apparent on initial labs; assess BUN/creatinine ratio ≥18). 1, 3
• Screen for hypercalcemia (even with subtle symptoms like somnolence—40% reversible). 3
• Evaluate for hyponatremia (consider SIADH requiring specific testing). 1, 3
• Assess renal and hepatic function. 1

Often-Overlooked Physical Factors

• Systematically evaluate for pain using validated tools (PAINAD for non-verbal patients, numeric scales for verbal). 3, 4
• Check for constipation and urinary retention—both are common delirium triggers. 1, 3, 4
• Examine for pressure ulcers. 3
• Measure oxygen saturation and provide supplemental oxygen if needed—hypoxia is immediately reversible. 1, 3, 4

Neurological Causes

• Consider cerebrovascular events (stroke, TIA), traumatic brain injury, subdural hematoma, seizures, meningitis, or encephalitis when clinically indicated. 2, 3

Sensory and Environmental Factors

• Ensure patients use their glasses and hearing aids—sensory impairment significantly contributes to delirium. 2, 3, 4
• Address sleep deprivation, which both results from and perpetuates delirium. 3

Non-Pharmacological Management (First-Line)

Implement multicomponent non-pharmacological interventions immediately—these are the only evidence-based approaches that reduce delirium incidence and carry no risk of harm. 1, 2, 3, 5, 6

Core Intervention Components

• Cognitive reorientation: Frequently reassure and reorient to person, place, time using simple language, visible calendars, clocks, and caregiver identification. 1, 3
• Early mobilization: Initiate physical therapy and supervised mobility in short sessions throughout the day. 1, 2, 3, 6
• Sleep enhancement: Use non-pharmacological sleep protocols, reduce nighttime noise, provide adequate lighting during day, minimize relocations. 1, 3, 6
• Nutrition and hydration: Ensure adequate intake and correct deficiencies. 1, 6
• Pain management: Use scheduled acetaminophen or other non-opioid analgesics preferentially. 3, 6
• Therapeutic environment: Quiet room, one task at a time, familiar objects from home, consistent caregivers, family presence at bedside. 1, 3

Interdisciplinary Team Approach

• Engage physicians, nurses, physical/occupational therapists, and social workers for daily rounds with specific recommendations. 2, 3
• Provide formal education to all staff on delirium recognition and management. 3, 4

Pharmacological Management (Reserved for Severe Agitation Only)

Avoid antipsychotics for delirium prevention or routine treatment—evidence does not support their efficacy and they carry significant risks. 2, 5, 6

When Pharmacotherapy Is Considered

• Use antipsychotics only when the patient is severely agitated, threatening substantial harm to self or others, and only after non-pharmacological approaches have been attempted. 1, 2, 3
• Administer haloperidol at the lowest effective dose for the shortest duration (preferred over lorazepam for acute agitation). 1, 2
• Never use antipsychotics or benzodiazepines for hypoactive delirium. 3
• Consider dexmedetomidine for hyperactive delirium in mechanically ventilated or non-intubated patients when non-pharmacological measures fail. 2

Critical Restraint Guidance

• Minimize or eliminate physical restraints—they worsen delirium and increase complications. 1, 2, 3
• Minimize chemical restraint/sedation whenever possible. 1

Special Populations and Considerations

• In cancer patients, recognize that advanced age, cognitive impairment on admission, hypoalbuminemia, bone metastases, and hematological malignancies increase delirium risk. 1
• Chemotherapy-induced delirium can occur with methotrexate, cisplatin, vincristine, ifosfamide, high-dose cytarabine, and others. 1
• In patients with pre-existing dementia, multicomponent interventions show uncertain benefit, requiring heightened vigilance. 1

Prognostic Implications

Recognize that delirium is a medical emergency with mortality rates twice as high when missed, and overall mortality in altered mental status patients approximates 8.1% (higher in elderly). 3 Delirium increases risk of functional decline, institutionalization, prolonged hospitalization, and death. 2, 6

Key Pitfalls to Avoid

• Do not delay treatment of underlying causes—this prolongs delirium and worsens cognitive outcomes. 2, 3
• Do not overlook polypharmacy or fail to perform medication reconciliation. 2
• Do not use antipsychotics as first-line treatment or for prevention. 2, 5
• Do not restrain patients to manage behavioral symptoms. 1, 2, 3
• Do not miss hypoactive delirium—over 50% of delirium cases go undiagnosed. 3, 5