Evidence-Based Reviews

Hospitalized, elderly, and delirious: What should you do for these patients?

Current Psychiatry. 2013 August;12(8):10-18

References

1. Diagnostic and statistical manual of mental disorders, 5th ed. Arlington, VA: American Psychiatric Association; 2013.

2. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990;113:941-948.

3. Liptzin B, Levkoff SE. An empirical study of delirium subtypes. Br J Psychiatry. 1992;161:843-845.

4. Martins S, Fernandes L. Delirium in elderly people: a review. Front Neurol. 2012;3:101.

5. Levkoff SE, Liptzin B, Evans D, et al. Progression and resolution of delirium in elderly patients hospitalized for acute care. Am J Geriatr Psychiatry. 1994;2:230-238.

6. O’Keefe S, Lavan J. The prognostic significance of delirium in older hospitalized patients. J Am Geriatr Soc. 1997;45:247-248.

7. Tsai MC, Weng HH, Chou SY, et al. One-year mortality of elderly inpatients with delirium, dementia or depression seen by a consultation-liaison service. Psychosomatics. 2012;53:433-438.

8. Rockwood K, Cosway S, Carver D, et al. The risk of dementia and death after delirium. Age Ageing. 1999;28:551-556.

9. Marcantonio E, Flacker JM, Michaels M, et al. Delirium is independently associated with poor functional recovery after hip fracture. J Am Geriatr Soc. 2000;48:618-624.

10. Dolan MM, Hawkes WG, Zimmerman SI, et al. Delirium on hospital admission in aged hip fracture patients: prediction of mortality and 2-year functional outcomes. J Gerontol A Biol Sci Med Sci. 2000;55:M27-M34.

11. Marcantonio ER, Kiely DK, Simon SE, et al. Outcomes of elders admitted to post-acute facilities with delirium. J Am Geriatr Soc. 2005;53:963-969.

12. Bledowski J, Trutia A. A review of pharmacologic management and prevention strategies of delirium in the intensive care unit. Psychosomatics. 2012;53:203-211.

13. Breitbart W, Alici-Evcimen Y. Why off-label antipsychotics remain first-choice drugs for delirium. Current Psychiatry. 2007;6(9):49-63.

14. Lonergan E, Luxenberg J, Areosa Sastre A. Benzodiazepines for delirium. Cochrane Database Syst Rev. 2009;(4):CD006379. doi: 10.1002/14651858.CD006379.pub3.

15. Brummel NE, Girard TD. Preventing delirium in the ICU. Crit Care Clin. 2013;(29):51-65.

16. Overshott R, Karim S, Burns A. Cholinesterase inhibitors for delirium. Cochrane Database Syst Rev. 2008(1):CD005317. doi: 10.1002/14651858.CD005317.

17. Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340:669-676.

18. Francis J, Martin D, Kapoor WN. A prospective study of delirium in hospitalized elderly. JAMA. 1990;263:1097-1101.

More recently, cholinesterase inhibitors have been used to treat delirium. The reasoning behind their use is the hypothesis of a central cholinergic deficiency in delirium.¹² Regrettably, there have been few well-conducted studies of these agents in delirium, and a Cochrane review found no significant benefit for cholinesterase inhibitors.¹⁶ With the same hypothesis in mind, anticholinergic medications in patients with delirium should be avoided because these agents could exacerbate delirium by further decreasing the acetylcholine level.

Because delirium is common in the hospitalized population (especially older patients), a number of studies have examined strategies to prevent or reduce its development. Inouye and colleagues conducted a controlled clinical trial, in which they intervened to reduce six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual and hearing impairment, and dehydration in hospitalized geriatric patients. The number and duration of events of delirium were significantly lower in the intervention group.¹⁷

Brummel et al reported that reducing modifiable risk factors in intensive care unit patients—including sedation management, minimizing deliriogenic medications (anticholinergics, antihistamines), minimizing sleep disruption, and encouraging early mobility—could prevent or reduce the incidence of delirium.¹⁵

CASE CONCLUDED: Return to baseline

Ms. T’s medications are minimized or discontinued, including azithromycin, based on case reports in the literature. She is stabilized hemodynamically.

Clinicians educate Ms. T’s family about delirium. To address Ms. T’s aggressive and paranoid behaviors, clinicians request that a family member is present to reassure Ms. T. She is continued on low-dose haloperidol. The family also is asked to bring Ms. T’s hearing aid and eyeglasses.

MRI is performed after Ms. T’s behavior is under control. The scan is negative for a new stroke.

Repeat blood tests the following day show an elevated white blood cell count; urinalysis is positive for a urinary tract infection. Ms. T is started on antibiotics. Subsequent urine culture shows no bacterial growth; the antibiotics are stopped after 3 days.

Ms. T slowly improves. According to her family, she is back at baseline in 3 or 4 days.

This case illustrates the complexity of trying to identify the precise cause of delirium among the many that could be involved. Often, no single cause can be found.¹⁸

Bottom Line
Delirium is a common and potentially life-threatening condition in hospitalized geriatric patients. General hospital psychiatrists should know how to recognize and treat the condition in collaboration with their medical colleagues.

Related Resources

Treating delirium: a quick reference guide. Arlington, VA: American Psychiatric Association. http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1662986.
Cook IA. Guideline watch: practice guidelines for the treatment of patients with delirium. http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1681952.
Fearing MA, Inouye SK. Delirium. In: Blazer DG, Steffens D, eds. The American Psychiatric Publishing textbook of geriatric psychiatry. 4th ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2009:229-241.
Ghandour A, Saab R, Mehr D. Detecting and treating delirium—key interventions you may be missing. J Fam Pract. 2011;60(12):726-734.
Leentjens AF, Rundell J, Rummans T, et al. Delirium: an evidence-based medicine (EBM) monograph for psychosomatic medicine practice. J Psychosom Res. 2012;73:149-152.
Liptzin B, Jacobson SA. Delirium. In: Sadock BJ, Sadock VA, Ruiz P, eds. Comprehensive textbook of psychiatry. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2009:4066-4073.

Drug Brand Names

Azithromycin • Zithromax Hydralazine • Apresoline

Diltiazem • Cardizem Risperidone • Risperdal

Haloperidol • Haldo

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Featured Audio
Benjamin Liptzin, MD, describes the distinction between dementia and delirium. Dr. Liptzin is Chair of Psychiatry, Baystate Medical Center, Springfield, Massachusetts, and Professor and Deputy Chair, Department of Psychiatry, Tufts University School of Medicine, Boston, Massachusetts.