Evidence-Based Reviews

Delirium in the hospital: Emphasis on the management of geriatric patients

Current Psychiatry. 2014 August;13(8):29, 36-42, A

References

1. Diagnostic and statistical manual of mental disorders, fifth edition. Washington, DC: American Psychiatric Association; 2013.
2. World Health Organization. The ICD-10 classification of mental and behavioural disorders. Diagnostic criteria for research. Geneva, Switzerland: WHO; 1993.
3. Lipowski ZJ. Delirium in the elderly patient. N Engl J Med. 1989;320(9):578-582.
4. Meagher DJ, Trzepacz PT. Motoric subtypes of delirium. Semin Clin Neuropsychiatry. 2000;5(2):75-85.
5. Rabinowitz T. Delirium: an important (but often unrecognized) clinical syndrome. Curr Psychiatry Rep. 2002;4(3):202-208.
6. Marcantonio ER, Ta T, Duthie E, et al. Delirium severity and psychomotor types: their relationship with outcomes after hip fracture repair. Am J Geriatr Soc. 2002;50(5):850-857.
7. Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001;286(21):2703-2710.
8. Duppils GS, Wikblad K. Delirium: behavioural changes before and during the prodromal phase. J Clin Nurs. 2004;13(5):609-616.
9. de Jonghe JF, Kalisvaart KJ, Dijkstra M, et al. Early symptoms in the prodromal phase of delirium: a prospective cohort study in elderly patients undergoing hip surgery. Am J Geriatr Psychiatry. 2007;15(2):112-121.
10. Cook IA. Guideline watch: practice guideline for the treatment of patients with delirium. Arlington, VA: American Psychiatric Publishing; 2004.
11. Hogan D, Gage L, Bruto V, et al. National guidelines for seniors’ mental health: the assessment and treatment of delirium. Canadian Journal of Geriatrics. 2006;9(suppl 2):S42-51.
12. Leentjens AF, Diefenbacher A. A survey of delirium guidelines in Europe. J Psychosom Res. 2006;61(1):123-128.
13. Tropea J, Slee JA, Brand CA, et al. Clinical practice guidelines for the management of delirium in older people in Australia. Australas J Ageing. 2008;27(3):150-156.
14. Mittal D, Majithia D, Kennedy R, et al. Differences in characteristics and outcome of delirium as based on referral patterns. Psychosomatics. 2006;47(5):367-375.
15. Grover S, Subodh BN, Avasthi A, et al. Prevalence and clinical profile of delirium: a study from a tertiary-care hospital in north India. Gen Hosp Psychiatry. 2009;31(1): 25-29.
16. 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(12): 941-948.
17. Strawn JR, Keck PE Jr, Caroff SN. Neuroleptic malignant syndrome. Am J Psychiatry. 2007;164(6):870-876.
18. Dobmejer K. Delirium in elderly medical patients. Clinical Geriatrics. 1996;4:43-68.
19. Leentjens AF, Maclullich AM, Meagher DJ. Delirium, Cinderella no more...? J Psychosom Res. 2008;65(3):205.
20. Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol. 2009;5(4):210-220.
21. Streubel PN, Ricci WM, Gardner MJ. Fragility fractures: preoperative, perioperative, and postoperative management. Current Orthopaedic Practice. 2009;20(5):482-489.
22. Spronk PE, Riekerk B, Hofhuis J, et al. Occurrence of delirium is severely underestimated in the ICU during daily care. Intensive Care Med. 2009;35(7):1276-1280.
23. Lawlor PG, Gagnon B, Mancini IL, et al. Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Arch Intern Med. 2000;160(6):786-794.
24. Ganzini L. Care of patients with delirium at the end of life. Annals of Long-Term Care. 2007;15(3):35-40.
25. Bourne RS, Tahir TA, Borthwick M, et al. Drug treatment of delirium: past, present and future. J Psychosom Res. 2008;65(3):273-282.
26. Yokota H, Ogawa S, Kurokawa A, et al. Regional cerebral blood flow in delirium patients. Psychiatry Clin Neurosci. 2003;57(3):337-339.
27. Maldonado JR. Pathoetiological model of delirium: a comprehensive understanding of the neurobiology of delirium and an evidence-based approach to prevention and treatment. Crit Care Clin. 2008;24(4):789-856, ix.
28. Trzepacz PT. Is there a final common neural pathway in delirium? Focus on acetylcholine and dopamine. Semin Clin Neuropsychiatry. 2000;5(2):132-148.
29. Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med. 1994;97(3):278-288.
30. Laurila JV, Laakkonen ML, Tilvis RS, et al. Predisposing and precipitating factors for delirium in a frail geriatric population. J Psychosom Res. 2008;65(3):249-254.
31. Morandi A, McCurley J, Vasilevskis EE, et al. Tools to detect delirium superimposed on dementia: a systematic review. J Am Geriatr Soc. 2012;60(11):2005-2013.
32. Kazmierski J, Kowman M, Banach M, et al. The use of DSM-IV and ICD-10 criteria and diagnostic scales for delirium among cardiac surgery patients: results from the IPDACS study. J Neuropsychiatry Clin Neurosci. 2010; 22(4):426-432.
33. Breitbart W, Rosenfeld B, Roth A, et al. The Memorial Delirium Rating Scale. J Pain Symptom Manage. 1997;13(3):128-137.
34. Wong CL, Holroyd-Leduc J, Simel DL, et al. Does this patient have delirium?: value of bedside instruments. JAMA. 2010;304(7):779-786.
35. Marcantonio ER, Flacker JM, Wright RJ, et al. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc. 2011;49(5):516-522.
36. Lundström M, Edlund A, Karlsson S, et al. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. J Am Geriatr Soc. 2005;53(4):622-628.
37. Lundström M, Olofsson B, Stenvall M, et al. Postoperative delirium in old patients with femoral neck fracture: a randomized intervention study. Aging Clin Exp Res. 2007; 19(3):178-186.
38. Kratz A. Use of the acute confusion protocol: a research utilization project. J Nurs Care Qual. 2008;23(4):331-337.
39. Prakanrattana U, Prapaitrakool S. Efficacy of risperidone for prevention of postoperative delirium in cardiac surgery. Anaesth Intensive Care. 2007;35(5):714-719.
40. Kaneko T, Cai J, Ishikura T, et al. Prophylactic consecutive administration of haloperidol can reduce the occurrence of postoperative delirium in gastrointestinal surgery. Yonago Acta Medica. 1999;42:179-184.
41. Larsen KA, Kelly SE, Stern TA, et al. Administration of olanzapine to prevent postoperative delirium in elderly joint-replacement patients: a randomized, controlled trial. Psychosomatics. 2010;51(5):409-418.
42. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc. 2005;53(10):1658-1666.
43. Hakim SM, Othman AI, Naoum DO. Early treatment with risperidone for subsyndromal delirium after on-pump cardiac surgery in the elderly: a randomized trial. Anesthesiology. 2012;116(5):987-997.
44. Maldonado JR, Wysong A, van der Starre PJ, et al. Dexmedetomidine and the reduction of postoperative delirium after cardiac surgery. Psychosomatics. 2009;50(3): 206-217.
45. Short J. Use of dexmedetomidine for primary sedation in a general intensive care unit. Crit Care Nurse. 2010;30(1): 29-38; quiz 39.
46. Practice guideline for the treatment of patients with delirium. American Psychiatric Association [Comment in: Treatment of patients with delirium. Am J Psychiatry. 2000.]. Am J Psychiatry. 1999;156(suppl 5):1-20.
47. Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis, and treatment. Crit Care Clin. 2008;24(4):657-722, vii.
48. Platt MM, Breitbart W, Smith M, et al. Efficacy of neuroleptics for hypoactive delirium. J Neuropsychiatry Clin Neurosci. 1994;6(1):66-67.
49. Lonergan E, Britton AM, Luxenberg J, et al. Antipsychotics for delirium. Cochrane Database Syst Rev. 2007;(2):CD005594.
50. Seitz DP, Gill SS, van Zyl LT. Antipsychotics in the treatment of delirium: a systematic review. J Clin Psychiatry. 2007;68(1):11-21.
51. Breitbart W, Marotta R, Platt MM, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry. 1996;153(2):231-237.
52. Hu H, Deng W, Yang H, et al. Olanzapine and haloperidol for senile delirium: a randomized controlled observation. Chinese Journal of Clinical Rehabilitation. 2006;10(42): 188-190.
53. Friedman JH, Fernandez HH. Atypical antipsychotics in Parkinson-sensitive populations. J Geriatr Psychiatry Neurol. 2002;15(3):156-170.
54. Seitz DP, Gill SS. Neuroleptic malignant syndrome complicating antipsychotic treatment of delirium or agitation in medical and surgical patients: case reports and a review of the literature. Psychosomatics. 2009; 50(1):8-15.
55. Han CS, Kim YK. A double-blind trial of risperidone and haloperidol for the treatment of delirium. Psychosomatics. 2004;45(4):297-301.
56. Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. JAMA. 2005;293(5):596-608.
57. Hermann N, Lanctôt KL. Atypical antipsychotics for neuropsychiatric symptoms of dementia: malignant or maligned? Drug Saf. 2006;29(10):833-843.
58. Noyan MA, Elbi H, Aksu H. Donepezil for anticholinergic drug intoxication: a case report. Prog Neuropsychopharmacol Biol Psychiatry. 2003;27(5):885-887.
59. Gleason OC. Donepezil for postoperative delirium. Psychosomatics. 2003;44(5):437-438.
60. Overshott R, Karim S, Burns A. Cholinesterase inhibitors for delirium. Cochrane Database Syst Rev. 2008;(1): CD005317.
61. Davis MP. Does trazodone have a role in palliating symptoms? Support Care Cancer. 2007;15(2):221-224.
62. Fick DM, Agostini JV, Inouye SK. Delirium superimposed on dementia: a systematic review. J Am Geriatr Soc. 2002; 50(10):1723-1732.
63. Brajtman S, Wright D, Hogan D, et al. Developing guidelines for the assessment and treatment of delirium in older adults at the end of life. Can Geriatr J. 2011;14(2):40-50.
64. Caraceni A, Simonetti F. Palliating delirium in patients with cancer. Lancet Oncol. 2009;10(2):164-172.
65. Alexopoulos GS, Streim J, Carpenter D, et al; Expert Consensus Panel for using Antipsychotic Drugs in Older Patients. Using antipsychotic agents in older patients. J Clin Psychiatry. 2004;65(suppl 2):5-99; discussion 100-102; quiz 103-104.
66. Granja C, Gomes E, Amaro A, et al. Understanding posttraumatic stress disorder-related symptoms after critical care: the early illness amnesia hypothesis. Crit Care Med. 2008;36(10):2801-2809.
67. Ringdal GI, Ringdal K, Juliebø V, et al. Using the Mini- Mental State Examination to screen for delirium in elderly patients with hip fracture. Dement Geriatr Cogn Disord. 2011;32(6):394-400.
68. Olson RA, Chhanabhai T, McKenzie M. Feasibility study of the Montreal Cognitive Assessment (MoCA) in patients with brain metastases. Support Care Cancer. 2008;16(11):1273-1278.

In controlled trials, atypical antipsychotics for delirium showed efficacy compared with haloperidol.^52,55 However, there is no research that demonstrates any advantage of one atypical over another.²⁵

In Mr. D’s case, the most important intervention for managing delirium caused by NMS is to discontinue all dopamine antagonists and treat agitation with judicious doses of a benzodiazepine, with supportive care.¹⁷ In cases of sudden discontinuation or a dosage decrease of dopamine agonists, these medications should be resumed or optimized to minimize the risk of NMS-associated rhabdomyolysis and subsequent renal failure.¹⁷ Antipsychotics carry an increased risk of stroke and mortality in older patients with established or evolving neurocognitive disorders^56,57 and can cause prolongation of the QTc interval.⁵⁷

Other medications that could be used for delirium include cholinesterase inhibitors^58,59 (although larger trials and a systematic review did not support this use⁶⁰), and 5-HT receptor antagonists,⁶¹ such as trazodone. Benzodiazepines, such as lorazepam, are first-line treatment for delirium associated with seizures or withdrawal from alcohol, sedatives, hypnotics, and anxiolytics and for delirium caused by NMS. Be cautious about using benzodiazepines in geriatric patients because of a risk of respiratory depression, falls, sedation, and amnesia.

Geriatric patients with alcoholism and those with malnutrition are prone to thiamine and vitamin B₁₂deficiencies, which can induce delirium. Laboratory assessment and consideration of supplementation is recommended. Despite high occurrence of delirium in hospitalized older adults with preexisting comorbid neurocognitive disorders, there is no standard care for delirium comorbid with another neurocognitive disorder.⁶² Clinical practice guidelines for older patients receiving palliative care have been developed⁶³; the goal is to minimize suffering and discomfort in patients in palliative care.⁶⁴

Post-delirium prophylaxis. Medications for delirium usually can be tapered and discontinued once the episode has resolved and the patient is stable; it is common to discontinue medications when the patient has been symptom-free for 1 week.⁶⁵ Some patients (eg, with end-stage liver disease, disseminated cancer) are prone to recurrent or to prolonged or chronic delirium. A period of post-recovery treatment with antipsychotics—even indefinite treatment in some cases—should be considered.

Post-delirium debriefing and aftercare. The psychological complications of delirium are distressing for the patient and his (her) caregivers. Psychiatric complications associated with delirium, including acute stress disorder—which might predict posttraumatic stress disorder—have been explored; early recognition and treatment may improve long-term outcomes.⁶⁶ After recovery from acute delirium, cognitive assessment (eg, MMSE⁶⁷ or Montreal Cognitive Assessment⁶⁸) is recommended to validate current cognitive status because patients may have persistent decrement in cognitive function compared with pre-delirium condition, even after recovery from the acute episode.

Post-delirium debriefing may help patients who have recovered from a delirium episode. Patients may fear that their brief period of hallucinations might represent the onset of a chronic-relapsing psychotic disorder. Allow patients to communicate their distress about the delirium episode and give them the opportunity to talk through the experience. Brief them on the possibility that delirium will recur and advise them to seek emergency medical care in case of recurrence. Advise patients to monitor and maintain a normal sleep-wake cycle.

Family members can watch for syndromal recurrence of delirium. They should be encouraged to discuss their reaction to having seen their relative in a delirious state.

Health care systems with integrated electronic medical records should list “delirium, resolved” on the patient’s illness profile or problem list and alert the patient’s primary care provider to the delirium history to avoid future exposure to delirium-provocative medications, and to prompt the provider to assume an active role in post-delirium care, including delirium recurrence surveillance, medication adjustment, risk factor management, and post-recovery cognitive assessment.

Bottom Line
Evaluation of delirium in geriatric patients includes clinical vigilance and screening, differentiating delirium from other neurocognitive disorders, and identifying and treating underlying causes. Perioperative use of antipsychotics may reduce the incidence of delirium, although hospital length of stay generally has not been reduced with prophylaxis. Management interventions include staff education, systematic screening, use of multicomponent interventions, and pharmacologic interventions.

Related Resources
• Downing LJ, Caprio TV, Lyness JM. Geriatric psychiatry review: differential diagnosis and treatment of the 3 D’s - delirium, dementia, and depression. Curr Psychiatry Rep. 2013;15(6):365.
• Brooks PB. Postoperative delirium in elderly patients. Am J Nurs. 2012;112(9):38-49.

Drug Brand Names
Carbidopa/levodopa • Sinemet Midazolam • Versed
Dexmedetomidine • Precedex Olanzapine • Zyprexa
Haloperidol • Haldol Propofol • Diprivan
Lithium • Eskalith, Lithobid Quetiapine • Seroquel
Lorazepam • Ativan Risperidone • Risperdal
Metoclopramide • Reglan Trazodone • Desyrel

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

Delirium in the hospital: Emphasis on the management of geriatric patients

References

Pages

Recommended Reading

Related Articles

Evidence-Based Reviews

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

Evidence-Based Reviews

Delirium: Apply the ‘4 Ps’ for comprehensive treatment