Management of Delirium and Cognitive Decline in Geriatric Patients

Diagnosis and Assessment

The American Geriatrics Society recommends using validated screening tools such as the Confusion Assessment Method (CAM) to diagnose delirium, which is characterized by acute onset, fluctuating course, inattention, and disorganized thinking 1
Differentiate between hyperactive, hypoactive, and mixed delirium subtypes, noting that hypoactive delirium is more common in older adults and associated with greater morbidity and mortality 2, 3

The American Geriatrics Society recommends promptly evaluating and treating the underlying infection to prevent prolonged delirium, which is associated with worse cognitive and functional recovery 4, 5
Perform a comprehensive medical evaluation including appropriate diagnostic tests to identify and manage all contributing factors to delirium 4, 5
Implement multicomponent non-pharmacological interventions including mobility/exercise/physical therapy, reorientation, therapeutic activities, nutrition and hydration maintenance, and sleep enhancement 4, 5
Ensure proper vision and hearing adaptation by providing glasses and hearing aids to minimize sensory deprivation 4, 5
Avoid conventional antipsychotics like haloperidol or atypical antipsychotics for delirium prevention or treatment as evidence supporting their use is limited 2, 3
Consider dexmedetomidine for hyperactive delirium resolution in mechanically ventilated and non-intubated patients when non-pharmacological approaches fail 2, 3

Engage an interdisciplinary team to perform daily rounds providing both general and specific recommendations 4
Include geriatric consultation as part of multicomponent interventions to improve outcomes 4, 5
Provide education to nursing staff and other healthcare providers about delirium recognition and management 4, 5

Implement early mobility and physical rehabilitation to potentially shorten delirium duration and reduce cognitive decline 2, 3

Prevent the use of physical restraints to manage behavioral symptoms, as they may exacerbate delirium 4, 5
Do not delay treatment of underlying causes, as this can prolong delirium and worsen cognitive outcomes 4, 5

Consider specialized hospital units for the inpatient care of older adults with delirium, although evidence for their benefit is currently insufficient 5

The American College of Emergency Physicians suggests that urinary tract infections and pneumonia are the most frequently encountered infectious causes of delirium in older adults 6, 7
The American Geriatrics Society notes that anticholinergic medications are among the highest-risk medications for causing delirium 7, 8
The Journal of the American Geriatrics Society reports that benzodiazepines and other sedative-hypnotics significantly increase delirium risk 9, 10
The American College of Radiology states that cerebrovascular disease, including stroke and transient ischemic attacks, can cause delirium 11, 12

The American College of Emergency Physicians recommends determining onset and course, assessing attention and consciousness, and evaluating for presence of hallucinations to diagnose delirium 6, 7, 8
The Journal of the American Geriatrics Society suggests using validated screening tools such as the Confusion Assessment Method (CAM) or Brief Confusion Assessment Method 7

The American Geriatrics Society recommends identifying and treating underlying causes, avoiding high-risk medications, providing adequate hydration and nutrition, and ensuring proper oxygenation as non-pharmacological approaches to manage delirium 7, 8, 9
The American College of Emergency Physicians suggests using antipsychotics at lowest effective dose for shortest duration when non-pharmacological measures fail and patient poses risk to self or others 10

The American College of Emergency Physicians notes that attributing symptoms solely to dementia without investigating for acute causes is a common pitfall in delirium management 6, 8
The Journal of the American Geriatrics Society reports that overlooking the impact of polypharmacy and not performing medication reconciliation is a common pitfall in delirium management 9, 10