This is the second in an ongoing series highlighting issues faced by geriatricians and their patients
Prevention and Management of Delirium in the Hospital
by Donna Seminara, MD, MACP
Delirium, also known as metabolic encephalopathy or a change in mental status, is sudden severe confusion that occurs with physical or mental illness. Delirium is a medical emergency. Sequelae of delirium may persist for up to 6 months and it is associated with poor clinical outcomes including risk of death in the hospital, prolonged length of stay and increased need for SNF placement.
Identifying patients at risk is a cornerstone of delirium prevention. Patients who have previously experienced delirium are at risk for recurrence. For instance, patients who present for perioperative assessments with a history of hospital or post anesthesia delirium should have delirium risk addressed. Patients with all causes of dementia and those with mild cognitive impairment are also at risk. Consider also patients with alcohol, analgesic and anxiolytic withdrawal as being at risk for hospital based delirium.
Successful hospital management of patients at risk mandates close communication with hospitalists and surgical specialists about an individual’s predictive risk of delirium. For elective procedures, careful medication reconciliation preoperatively can decrease risk of medication induced encephalopathies. As was emphasized by Dr. Dharmarajan in the previous Geriatric Spotlight on Deprescription, doing what I call a “Medication Debridement” is a key focus of geriatric assessments. Geriatric consultations may be helpful in situations where polypharmacy is a trigger for delirium.1 Predict medication needs and address potential challenges to minimize delirium from occurring. For example a patient requiring stress dose steroids or ongoing steroid treatment with a history of delirium may require a more rapid steroid taper. Furthermore, transitioning information from previous experiences of the individualcan be extremely valuable for a patient’s safety (ie: documented ICU psychosis or adverse behavioral reactions to specific analgesics.)
A series of preventive measures can significantly decrease delirium risk in patients on medical/surgical units. Patients in the hospital should not have glasses, hearing aids, and dentures taken away for “safe keeping”. Patients sensorily deprived have increased difficulty in interpreting their highly charged hospital experience. Patients also need a good night’s sleep so avoidance of disturbances overnight is another key to delirium prevention. Early mobility and avoidance of dehydration are important factors to prioritize for older patients to avoid delirium.
A cornerstone of treating delirium is to identify it early. While 25% of older delirious patients are hyperactive, 75% are hypoactive. They are the quiet older persons who don’t make noise or cause problems for staff. The hypoactive patient is however at the same risk as the loud hyperactive “sundowner” who requires a lot of staff time and attention. Whatever the patient’s presentation, comprehensive analysis of data and observation is mandated. The culprit precipitating delirium is often multifactorial. The “Confusion Assessment Method” is helpful in quick bedside evaluations of patients suspected of having delirium, by assessing acute changes in mental status with fluctuating course, inattention, disorganized thinking and altered levels of consciousness.2
A common precipitant of delirium in hospitalized patients is the experience of pain. Barriers to adequate analgesia include the current predisposition against prescribing opioids and delay in medication delivery to patients. IV acetaminophen studies show promise in decreasing delirium risk and opioid use.3
Prescribers for older adults in the hospital need to remember the adage to “start low and go slow”. If a delirious patient requires antipsychotic medication to disrupt behaviors that acutely put the patient or staff at risk for harm, then starting with low doses of Haloperidol or Risperidone may be required.
Geriatric consultation is helpful. Complex older patients often require input from the whole team to best design a personalized care plan geared towards the best functional outcomes.