Delirium Diagnosis and Management in Elderly Patients

Priority Differential Diagnoses to Pursue

Over 80% of patients with bacteremia have neurological symptoms ranging from lethargy to coma, yet may not show obvious laboratory abnormalities initially, according to the American Society of Clinical Oncology 1
Urinary tract infection should be suspected and treated only when patient meets systemic sepsis criteria, as asymptomatic bacteriuria treatment worsens functional recovery and increases Clostridium difficile infections in elderly patients with delirium, as recommended by the American Society of Clinical Oncology 1
Anticholinergics, including antihistamines like cyclizine, should be avoided in elderly patients with delirium, as stated by the American Society of Anesthesiologists 2
Benzodiazepines are a strong precipitant of delirium and must be discontinued unless treating alcohol/benzodiazepine withdrawal, according to the American Society of Anesthesiologists 2
Opioids, particularly in patients with renal impairment, can accumulate metabolites and contribute to delirium, as noted by the American Society of Anesthesiologists 2

Hypercalcemia should be suspected even with indolent symptoms of confusion, asthenia, or drowsiness, as hypercalcemia-induced delirium is reversible in 40% of cases, according to the American Society of Clinical Oncology 1
Hyponatremia due to SIADH may require specific testing beyond basic metabolic panel, as recommended by the American Society of Clinical Oncology 1

Unrecognized pain is systematically undertreated in elderly patients, particularly those with cognitive impairment, and requires adequate assessment and management, as stated by the American Society of Anesthesiologists 2
Pressure injuries may cause pain-related delirium without obvious laboratory changes, according to the American Society of Anesthesiologists 2

Visual and hearing impairment contribute significantly to delirium, and ensuring patients have glasses and hearing aids in place is essential, as recommended by the American Geriatrics Society 3, 4
Sleep deprivation is both a symptom and perpetuating factor of delirium, and non-pharmacologic sleep protocols should be implemented, according to the American Geriatrics Society 3, 4
Dehydration is a common precipitating factor that may not be evident on initial laboratory studies, and adequate hydration should be ensured, as stated by the European Society for Clinical Nutrition and Metabolism 5, 6

A comprehensive medication review should be performed to discontinue all anticholinergics, benzodiazepines (except for alcohol withdrawal), and reduce opioids to minimum necessary doses, as recommended by the American Society of Anesthesiologists 2
Targeted physical examination should include checks for urinary retention, constipation, pressure injuries, and signs of pain, according to the American Geriatrics Society 3, 4

Empirical treatment of asymptomatic bacteriuria should be avoided, as it results in worse functional recovery and higher C. difficile infection rates, as stated by the American Society of Clinical Oncology 1
Neuroimaging should not be repeated unless new focal neurological findings develop, as sedation or restraints required for imaging can worsen delirium, according to the American Geriatrics Society 3, 4
Physical restraints should be avoided for managing behavioral symptoms, as they exacerbate delirium, as recommended by the American Geriatrics Society 3, 4

All elderly patients with delirium should receive multicomponent interventions by an interdisciplinary team, including reorientation, early mobilization, sleep hygiene, nutrition and hydration, and pain management, as recommended by the American Geriatrics Society 3, 4

The American Geriatrics Society recommends that a comprehensive medical evaluation should be performed immediately after delirium diagnosis to identify and manage contributing factors, as delayed treatment prolongs delirium and is associated with increased morbidity and mortality 7, 8, 9
The evaluation should include assessment of metabolic disturbances, such as hypoxia, electrolyte imbalances, hypoglycemia, and dehydration, as well as infections, medication review, and other potential causes 10, 11

The American Geriatrics Society recommends that non-pharmacological interventions should be the primary treatment for established delirium and should be implemented immediately by an interdisciplinary team 8, 11
Essential components of management include reorientation, optimization of sensory function, sleep hygiene, early mobilization, nutrition and hydration, pain management, and adequate oxygenation 9, 11

The American Geriatrics Society recommends that antipsychotics should be reserved for patients with severe agitation, extreme distress, or who pose a substantial threat to themselves or others, using the lowest effective dose for the shortest possible time 12, 13, 10
Benzodiazepines should not be used as first-line treatment for agitation associated with delirium, except in cases of alcohol or benzodiazepine withdrawal 12, 13, 10

Daily evaluation of delirium using validated tools, such as the Confusion Assessment Method (CAM), is recommended 14, 15
Antipsychotics should be discontinued immediately once acute distressing symptoms resolve 15

Ongoing educational programs on delirium should be provided for healthcare professionals 12, 13, 10

The American Geriatrics Society recommends avoiding physical restraints to manage behavioral symptoms of delirium, as they can exacerbate the condition 7, 8, 9
Excessive use of CT/MRI brain scans should be avoided, as sedation or restraints necessary for these studies can worsen delirium 7, 8, 9