Delirium in Older Persons: Evaluation and Management



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Am Fam Physician. 2014 Aug 1;90(3):150-158.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See the CME Quiz Questions.

  Patient information: See related handout on delirium, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Delirium is defined as an acute, fluctuating syndrome of altered attention, awareness, and cognition. It is common in older persons in the hospital and long-term care facilities and may indicate a life-threatening condition. Assessment for and prevention of delirium should occur at admission and continue throughout a hospital stay. Caregivers should be educated on preventive measures, as well as signs and symptoms of delirium and conditions that would indicate the need for immediate evaluation. Certain medications, sensory impairments, cognitive impairment, and various medical conditions are a few of the risk factors associated with delirium. Preventive interventions such as frequent reorientation, early and recurrent mobilization, pain management, adequate nutrition and hydration, reducing sensory impairments, and ensuring proper sleep patterns have all been shown to reduce the incidence of delirium, regardless of the care environment. Treatment of delirium should focus on identifying and managing the causative medical conditions, providing supportive care, preventing complications, and reinforcing preventive interventions. Pharmacologic interventions should be reserved for patients who are a threat to their own safety or the safety of others and those patients nearing death. In older persons, delirium increases the risk of functional decline, institutionalization, and death.

A 91-year-old woman with minimal English proficiency was admitted to the intensive care unit for an exacerbation of chronic obstructive pulmonary disease. Five days earlier, she had visited the emergency department for shoulder pain and was given acetaminophen with codeine. The patient's daughter reported that her mother did not comply with her chronic obstructive pulmonary disease inhaler regimen because of drowsiness brought on by the codeine. In the intensive care unit, oral food and fluids were withheld initially and the patient was given levofloxacin (Levaquin), methylprednisolone, nebulizer treatments, and ranitidine (Zantac). Overnight, she had urinary incontinence, which prompted placement of a catheter and initiation of tolterodine (Detrol) for bladder spasm. The next morning, her family arrived to find her in an anxious state, vacillating from mild fidgeting to abrupt sitting up to lying sideways on the bed. She had marked inattention and was unable to follow instructions or carry on conversation. She was confused about her whereabouts and claimed that hospital staff had attacked her.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Strength of recommendation References

Physicians should train nursing staff, home health aides, and family members/caregivers on recognizing and treating delirium.

C

3, 20, 21

The Confusion Assessment Method is the most effective tool in identifying delirium.

C

29

Assessment for and prevention of delirium should occur at admission to the hospital and throughout the stay.

C

3, 20, 21

Multicomponent prevention methods are effective in deterring delirium episodes.

B

20, 21, 33

Antipsychotic medications should be used as a last resort in treating delirium and should not be used indiscriminately in persons with delirium who have not been properly evaluated.

A

3644


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Strength of recommendation References

Physicians should train nursing staff, home health aides, and family members/caregivers on recognizing and treating delirium.

C

3, 20, 21

The Confusion Assessment Method is the most effective tool in identifying delirium.

C

29

Assessment for and prevention of delirium should occur at admission to the hospital and throughout the stay.

C

3, 20, 21

Multicomponent prevention methods are effective in deterring delirium episodes.

B

20, 21, 33

Antipsychotic medications should be used as a last resort in treating delirium and should not be used indiscriminately in persons with delirium who have not been properly evaluated.

A

3644


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

BEST PRACTICES IN GERIATRIC MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

Recommendation Sponsoring organization

Do not use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium.

American Geriatrics

The Authors

VIRGINIA B. KALISH, MD, is the geriatric care coordinator of the Family Medicine Clinic at Fort Belvoir (Va.) Community Hospital, and is a faculty member of the National Capitol Consortium Family Medicine Residency in Fort Belvoir.

JOSEPH E. GILLHAM, MD, is a staff physician at Robinson Health Clinic and adjunct faculty of the Womack Army Medical Center Family Medicine Residency, both in Fort Bragg, N.C. At the time this article was written, he was a second-year family medicine resident at the National Capitol Consortium Family Medicine Residency.

BRIAN K. UNWIN, MD, is section chief for geriatrics and palliative medicine at Carilion Clinic and an associate professor of family medicine and medicine at the Virginia Tech Carilion School of Medicine and Research Institute, both in Roanoke. At the time this article was written, he was an associate professor of family medicine and geriatrics at the Uniformed Services University of the Health Sciences, Bethesda, Md.

Address correspondence to Virginia B. Kalish, MD, National Capitol Consortium, 9300 Dewitt Loop, Fort Belvoir, VA 22060 (e-mail: virginia.b.kalish.civ@health.mil). Reprints are not available from the authors.


The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army.

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