Approach to delrelium in old age with management

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delirium AND older adults

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NICE delirium prevention diagnosis management older adults guideline 2023

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https://www.nice.org.uk/guidance/cg103

Delirium in older adults: approach and management

Delirium is an acute medical emergency until proved otherwise. It is an acute, fluctuating disturbance in attention and awareness, usually due to one or more underlying illnesses, medications, or environmental insults. In older people, it is often multifactorial and may be the only early sign of serious infection, hypoxia, stroke, drug toxicity, or metabolic disease.

1. Recognize delirium

Suspect it when there is an acute change from baseline over hours to days, with fluctuation during the day:

Reduced attention: cannot recite months backwards, easily distractible
Altered alertness: drowsy, hypervigilant, agitated, or variable
Disorientation, short-term memory difficulty, disorganized thinking
Hallucinations or delusions, often visual
Altered sleep-wake cycle
New agitation, falls, withdrawal, poor oral intake, or failure to cooperate

Hypoactive delirium is common in frail older adults and is easily missed. The person may appear quiet, sleepy, slowed, and disengaged rather than agitated.

Delirium vs dementia

Feature	Delirium	Dementia
Onset	Acute, hours to days	Gradual, months to years
Course	Fluctuates	Usually progressive and stable day-to-day
Attention	Markedly impaired	Often relatively preserved early
Conscious level	Altered or variable	Usually normal
Reversibility	Often reversible if cause treated	Usually not fully reversible

Dementia is a major risk factor, and delirium can occur on top of dementia. Ask family or carers about the patient's usual cognition and function. Rosen's Emergency Medicine distinguishes delirium by acute onset, impaired attention, and fluctuation, unlike the usual chronic course of dementia.

2. Confirm with a validated bedside tool

Use the 4AT for rapid assessment in hospital, emergency, or care-home settings.
CAM may be used where staff are trained.
Assess and document:
- baseline cognition and function
- onset and fluctuation
- attention and level of consciousness
- psychomotor subtype: hyperactive, hypoactive, or mixed
- capacity, distress, and immediate risk to self or others

NICE recommends a structured assessment when there are indicators of delirium. See the NICE delirium guideline.

3. Immediate assessment: stabilize and find the cause

A. Safety and ABCDE assessment

Check airway, breathing, circulation, temperature, oxygen saturation, glucose, and pain.
Give oxygen if hypoxic.
Correct hypoglycaemia urgently.
Assess dehydration, urinary retention, constipation, pressure injury, and uncontrolled pain.
Identify fall risk, aspiration risk, and risk of harm.

B. Look for common precipitants: use PINCH ME

Prompt	Examples
Pain	Fracture, urinary retention, pressure sores, postoperative pain
Infection	UTI, pneumonia, sepsis, COVID-19, skin infection
Nutrition	Dehydration, starvation, electrolyte disturbances
Constipation	Fecal impaction
Hydration / hypoxia	Dehydration, hypoxaemia, hypercapnia, anaemia
Medications	Anticholinergics, opioids, benzodiazepines, sedatives, steroids, antihistamines, dopamine drugs, polypharmacy or withdrawal
Environment / endocrine / metabolic	New surroundings, sleep deprivation, alcohol withdrawal, renal/hepatic failure, sodium/calcium disturbance, thyroid disease

Also consider:

Stroke, subdural hematoma, seizure or postictal state
Myocardial infarction or heart failure
Alcohol or sedative-hypnotic withdrawal
Poisoning or drug toxicity
Severe depression or psychosis only after medical causes have been considered

A medication review is essential because therapeutic-dose adverse effects and drug interactions are common causes in older patients. Infection, especially occult chest or urinary infection, is also frequent. Rosen's Emergency Medicine, Diagnostic Studies and Management sections.

C. Focused investigations

Tailor investigations to history and examination. Common initial tests include:

Capillary blood glucose
Pulse oximetry, ECG
FBC, urea/electrolytes/creatinine, calcium, liver function tests
CRP and cultures if sepsis is suspected
Urinalysis and urine culture only when clinical features suggest UTI
Chest radiograph if respiratory symptoms, hypoxia, fever, or unclear infection source
Blood gas if hypercapnia, respiratory failure, or significant acid-base disturbance is possible
Drug levels or toxicology when indicated
CT head if focal neurological deficit, trauma/fall, reduced consciousness without explanation, anticoagulant use with possible head injury, or concern for intracranial pathology

Do not attribute delirium to a positive urine dipstick alone. Asymptomatic bacteriuria is common in older adults.

4. Management

Treat the underlying cause

Examples:

Fluids and correction of electrolyte abnormalities for dehydration
Antibiotics and source control for confirmed or strongly suspected infection
Relieve urinary retention or fecal impaction
Treat hypoxia, hypercapnia, anaemia, heart failure, or pain
Stop, reduce, or substitute deliriogenic drugs where clinically safe
Treat alcohol or benzodiazepine withdrawal using an appropriate monitored protocol
Treat stroke, seizure, intracranial bleed, or myocardial infarction urgently when suspected

Management should focus primarily on correcting precipitating factors. Older adults with greater baseline vulnerability can develop delirium from relatively minor stressors. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry, p. 3741.

Non-drug treatment: first-line for nearly everyone

Use a calm, consistent, supportive environment:

Explain where the patient is and what is happening, repeatedly and simply.
Involve family or familiar carers where possible.
Provide clock, calendar, adequate lighting, visible staff, and clear day-night cues.
Ensure hearing aids, glasses, dentures, and mobility aids are available and working.
Encourage fluids, nutrition, supervised mobility, and daytime activity.
Avoid unnecessary room changes, noise, overnight disturbance, restraints, and prolonged bed rest.
Monitor and treat pain regularly.
Promote sleep without sedatives: reduce noise/light at night, avoid unnecessary observations if safe.
Use one-to-one observation or a family member for severe confusion and safety risk.
Review medication every day and minimize anticholinergic and sedating burden.

Physical restraint generally worsens fear, agitation, injury risk, and delirium. Use only as a last resort under local policy when immediate safety cannot otherwise be maintained.

Medication for severe distress or dangerous agitation

Medication is not routine treatment for delirium and does not treat its cause.

Consider short-term medication only if the person has severe distress, dangerous agitation, or is preventing essential care after:

correcting reversible causes,
using verbal and environmental de-escalation, and
assessing pain, retention, hypoxia, withdrawal, and medication effects.

A clinician may consider a low-dose antipsychotic for the shortest possible period, with close monitoring and local prescribing guidance. ECG/QT-risk and drug interactions should be considered.

Avoid or seek specialist advice with:

Parkinson disease or Lewy body dementia: antipsychotics can cause severe sensitivity reactions and worsen parkinsonism.
Prolonged QT interval, significant arrhythmia, or interacting QT-prolonging drugs.
Suspected alcohol, benzodiazepine, or sedative withdrawal: benzodiazepines may be appropriate for withdrawal but generally worsen non-withdrawal delirium.
Frail patients with dementia, where antipsychotics have important cerebrovascular and mortality risks.

5. Monitoring, disposition, and prevention

Reassess cognition, attention, consciousness, vital signs, hydration, bowel/bladder status, pain, and agitation at least daily, more often if unstable.
Document the likely causes, treatment response, and baseline cognitive status.
Admit or escalate urgently if delirium is new and unexplained, severe, associated with sepsis/organ dysfunction, focal deficits, trauma, or inability to maintain safe hydration/nutrition.
On recovery, reassess cognition. Persistent deficits may reveal underlying dementia or another neurological illness.
Explain to family that recovery may take days to weeks and sometimes longer.

Prevention bundle for high-risk older adults

Apply from admission or arrival in a care setting:

Identify cognitive impairment, prior delirium, frailty, severe illness, visual/hearing impairment, and dehydration.
Maintain orientation, hydration, nutrition, mobility, sensory aids, pain control, sleep hygiene, and medication review.
Avoid unnecessary catheters, restraints, sedatives, and anticholinergic drugs.

A recent systematic review confirms delirium is associated with important adverse outcomes among older inpatients, including higher mortality risk (PMID 40369782). This does not change the core approach above, but reinforces the need for early recognition and cause-directed treatment.

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