Prevention and Management of Delirium in the Hospital
This is the second in an ongoing series highlighting issues faced by geriatricians and their patients

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 individual can be extremely valuable for a patient’s safety (ie: documented  ICU psychosis or adverse behavioral reactions to specific analgesics.)

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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.

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