Delirium in Older Persons: Advances in Diagnosis and Treatment

Abstract

Importance: Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has serious adverse effects on the individual's function and quality of life, as well as broad societal effects with substantial health care costs.

Objective: To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field.

Evidence review: Search of Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011, until March 16, 2017, using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded.

Findings: Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment; 4 A's Test; and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method-Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of delirium, based on recent reviews of the evidence, recommend reserving use of antipsychotics and other sedating medications for treatment of severe agitation that poses risk to patient or staff safety or threatens interruption of essential medical therapies.

Conclusions and relevance: Advances in diagnosis can improve recognition and risk stratification of delirium. Prevention of delirium using nonpharmacologic approaches is documented to be effective, while pharmacologic prevention and treatment of delirium remains controversial.

Figure. Suggested Algorithm for Delirium Evaluation and Treatment^a

CBC indicates complete blood cell count; CT, computed tomography; EEG, electroencephalogram; EKG, electrocardiogram; MRI, magnetic resonance imaging. ^aAlthough the algorithm is evidence-based, it has not been validated. ^bCommon delirium risk factors include dementia or cognitive impairment, functional or mobility impairment, visual or hearing impairment, dehydration, sleep deprivation, history of alcohol misuse, advanced age (> 70 years), multiple coexisting medical illnesses, and presence of specific comorbidities (eg, stroke, depression). ^cDelirium should be considered a life-threatening medical emergency until proven otherswise; therefore, the presence of an acute change in mental status should trigger a rapid evaluation. Increasingly, many hospitals are incorporating delirium pathways (standing order sets for evaluation and treatment of delirium), implementation of delirium screening tools into the electronic medical record, and dedicated delirium wards/services. ^dDelirium is diagnosed in the presence of the following core features: (1) acute and fluctuating mental status change from baseline; (2) inattention PLUS (3) disorganized thinking OR (4) altered level of consciousness. ^eThe Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (Beers Criteria) can help identify medications that should be avoided or used at lowest possible dose. This includes tricyclic antidepressants, anticholinergics, antihistamines (eg, diphenhydramine), benzodiazepines, corticosteroids, H₂-receptor antagonists, meperidine, sedative-hypnotics, thioridazine, and chlorpromazine. ^fMulticomponent, nonpharmacologic strategies should be used for both delirium prevention and treatment. ^gReserve antipsychotic medications for use only when behvaiors (ie, agitation, hallucinations) pose a serios safety hazard to patient, staff, or both or when there is risk of interrupting essential medical care.