Clinical Pearls & Morning Reports
Delirium is extremely common in hospitalized older adults. In the hospital, delirium is a potent risk factor for complications, a longer length of stay, and discharge to a postacute nursing facility. Studies comparing clinical documentation with research assessments suggest that only 12 to 35% of delirium cases are recognized. Read the latest Clinical Practice Article.
Q: Is delirium in hospitalized older adults always characterized by agitation?
A: Although many clinicians think of patients with delirium as being agitated, hyperactive delirium represents only 25% of cases, with the others having hypoactive (“quiet”) delirium. Hypoactive delirium is associated with a poorer prognosis, potentially because it is less frequently recognized.
Q: Is delirium in hospitalized older adults usually transient?
A: The classic teaching is that delirium is transient; however, a growing literature shows that this is not always true. A systematic review showed that incident hospital delirium persisted at hospital discharge in 45% of cases and 1 month later in 33% of cases.
A: Addressing all modifiable contributors to delirium that are identified in the evaluation is critically important, and multiple small interventions can yield substantial benefit. Medications are the most common modifiable contributors. The hospital ward should be well lit during the day, dark and quiet at night. Interventions to improve orientation and reduce sensory deprivation include clocks, calendars, and encouragement of patients to wear eyeglasses and hearing aids. On the basis of clinical experience as well as a lack of evidence of benefit (and the recognized potential harms) of drug treatment, nonpharmacologic interventions are the cornerstone of managing behavioral problems in delirium. Pharmacologic treatment may be required for distressing perceptual disturbances or delusional thoughts when verbal reassurance is not successful or for behavior that is dangerous to the patient or others. Benzodiazepines should be reserved for specific indications, such as delirium associated with alcohol or benzodiazepine withdrawal, in which preventive administration may also be indicated. For other cases, antipsychotic agents have a more favorable risk–benefit ratio. A recent meta-analysis reviewed 12 randomized trials of antipsychotic agents for delirium treatment and concluded that they did not reduce the duration or severity of delirium, the length of stay in the ICU or hospital, or mortality. Thus, the decision whether to use such agents must consider the trade-off between an immediate reduction of agitation, hallucinations, and delusions versus the risks of sedation and antipsychotic-induced complications.
A: In a 1999 study, a unit-based proactive multifactorial intervention, the Hospital Elder Life Program (HELP), reduced the incidence of delirium among hospitalized patients who were 70 years of age or older. Interventions that were implemented by trained volunteers on the basis of risk factors for delirium that were present at hospital admission included reorientation, a nonpharmacologic sleep protocol, getting the patient out of bed and walking, encouraging the use of eyeglasses and hearing aids, and encouraging fluid intake. Another effective nonpharmacologic approach for delirium prevention is proactive geriatrics consultation in surgical patients at high risk for delirium. Geriatrics–orthopedics services have been widely adopted for patients with hip fracture, and similar protocols can be implemented by trained hospital medicine physicians. Reducing the use of psychoactive medications is an important component of the prevention strategies described above. Observational studies have suggested a potential benefit of reducing the use of sedating medications, such as sleeping pills, and reducing the use of deep sedation in the intensive care unit. The effectiveness of pharmacologic approaches for delirium prevention remains unclear. Melatonin and its analogues have also been proposed to reduce the incidence of delirium. A recent Cochrane review that pooled data from three trials involving 529 patients concluded that there is no clear evidence that the use of melatonin or melatonin agonists reduces the incidence of delirium as compared with placebo.