Delirium

AUTHOR: Fred F. Ferri, MD

Definition

The American Psychiatric Association’s Diagnostic and Statistical Manual, 5th edition (DSM-5), defines delirium as:

Disturbance of consciousness with reduced ability to focus, sustain, or shift attention.
The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of a day.
An additional disturbance in cognition (e.g., memory deficit, disorganization, language, visuospatial ability, or perception).
A change in cognition or development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.
There is evidence from history, physical exam, or lab findings that the disturbance is caused by medical condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies.

Synonyms

Acute confusional state

Toxic or metabolic encephalopathy

Theories Regarding Pathophysiology

Neuroinflammation, with increased permeability of the blood-brain barrier
Acetylcholine deficiency
Other neurotransmitter imbalances, including excesses of norepinephrine, serotonin, and, most important, dopamine

Classification

Hyperactive, hypoactive, and mixed subtype

ICD-10CM CODES
F05		Delirium, not induced by alcohol and other psychoactive substances
F05.9		Delirium, unspecified
F06.0		Organic hallucinosis
F05.8		Other delirium
F05.0		Delirium not superimposed on dementia
F05.1		Delirium superimposed on dementia

Epidemiology & Demographics

Nearly 30% of older patients experience delirium at some time during the hospital course. In older surgical patients, the risk varies from 10% to 50%. Hypoactive is more common. Predisposing factors for delirium among older adults hospitalized for a medical or surgical illness are summarized in Table 1. Delirium is the most common mental disorder in patients with medical illness. Any age, race, or gender can be affected. Predisposing factors for the development of delirium during hospitalization are summarized in Table 2. Pediatric delirium is often missed but remains important because delirium is associated with longer hospital stays, decreased cognitive performance, and increased mortality. Risk factors include extremes of age, severe pain, illicit substance use, surgery, dementia, and kidney or liver failure (Table 3).

TABLE 3 Mnemonic for Risk Factors for Delirium and Agitation

I Watch Death		Delirium
Infection		Drugs
Withdrawal		Electrolyte and physiologic abnormalities
Acute metabolic		Lack of drugs (withdrawal)
Trauma/pain		Infection
Central nervous system pathology		Reduced sensory input (blindness, deafness)
Hypoxia		Intracranial problems (CVA, meningitis, seizure)
Deficiencies (vitamin B₁₂, thiamine)		Urinary retention and fecal impaction
Endocrinopathies (thyroid, adrenal)		Myocardial problems (MI, arrhythmia, CHF)
Acute vascular (hypertension, shock)
Toxins/drugs
Heavy metals

CHF, Congestive heart failure; CVA, cerebrovascular accident; MI, myocardial infarction.

From Vincent JL et al: Textbook of critical care, ed 6, Philadelphia, 2011, Saunders.

TABLE 2 Precipitating Factors for the Development of Delirium During Hospitalization for Medical or Surgical Illness

Precipitating Factor		Odds Ratio (OR)
Use of physical restraints		4.4
Malnutrition		4
Using more than threenew medications during hospitalization		2.9
Use of bladder catheterization		2.4
Exposed to any iatrogenic event		1.9
Intraoperative hypotension(at least 31% drop inmean perioperative BPor a SBP ≤80 mmHg		1.4
Postoperative Hct <30%		1.7
Untreated postoperative pain		5.4-9
Use of anticholinergic drug		1.5-2.7

BP, Blood pressure; Hct, hematocrit; SBP, systolic blood pressure.

From Warshaw G et al: Ham’s primary care geriatrics, ed 7, Philadelphia, 2022, Elsevier.

TABLE 1 Predisposing Factors for Delirium Among Older Adults Hospitalized for a Medical or a Surgical Illness

Risk Factor	Odds Ratio (OR) Range ^a	The Delirium Vulnerability Scale
Cognitive Impairment: Chart diagnosis of dementia MMSE <24 Prior history of delirium	3.5-5 2-4 4	Choose one score only 3 points 2 points 1 point
Current history of depression	2-4	1 point
Current history of alcohol abuse	3-6.5	2 points
Current and untreated hearing loss	2	1 point
Current and untreated vision loss	2-3.5	1 point
Need assistance in two basic activities of daily living	2.5	1 point
Current use of anticholinergic	1.5-2.7	2 points
Dehydration defined by BUN/creatinine >21:1	1.8-2	1 point
Sodium abnormality (Na <130 or Na >150)	2-4	1 point
Vascular risk factors: history of: Hypertension Congestive heart failure Diabetes mellitus Cerebrovascular accident Atrial fibrillation	2.3 1.3-2.9 1.3 2.2 1.4	Choose a score of 1 point if at least one risk factor was present (maximum score is also 1 point)
Admitted for
Urgent surgical repair of hip fracture Elective aortic aneurysm repair	3 6	2 points 3 points
Total Points		_______ [range 0-17]
Interpretation: 0-1 point 2-3 points 4-7 points >7 points	Risk category Low Mild Moderate Severe	Probability of developing delirium ^b <5% 5%-20% 21%-40% >40%

BUN, Blood urea nitrogen; MMSE, Mini-Mental State Examination.

^aOR estimates were based on review of the literature.

^bDelirium probability estimates for each risk category were based on a literature review and the authors’ clinical and research experiences. The delirium vulnerability scale has not been validated in a prospective cohort study.

From Warshaw G et al: Ham’s primary care geriatrics, ed 7, Philadelphia, 2022, Elsevier.

Physical Findings & Clinical Presentation

One of the earliest symptoms is change in level of awareness and ability to focus, sustain, or shift attention. Symptoms may differ both among patients and within one patient. Family members or caregivers report that the patient “isn’t acting quite right.” Symptoms may include poor attention, sleepiness, agitation, or psychosis.
Acuteness of presentation helps in differentiating delirium with dementia. Change in cognition, perceptual problems (such as visual, auditory, or somatosensory hallucination usually with lack of insight), memory loss, disorientation, difficulty with speech and language. It is important to ascertain from family member or caregivers the patient’s level of functioning before onset of delirium.
Elderly patients with delirium often do not look sick, but patients with delirium are sick by definition.
Hyperactive delirium represents only 25% of cases, with the others having hypoactive (quiet) delirium.
There is often a prodrome phase that later blends into hypoactive delirium or erupts into an agitated confusional state.
Physical examination should be performed, focusing on signs of infection, dehydration, or chronic disease that may be exacerbated. Vital signs are key. Consider using the Mini-Mental Status Exam or the Montreal Cognitive Assessment.
Fig. 1 describes an algorithm for evaluation of mental status changes in an older patient.
Table 4 summarizes delirium assessment tools.

TABLE 4 Delirium Assessment Tools

Tool	Structure	Notes
Confusion Assessment Method (CAM)	Full scale of 11 items Abbreviated algorithm targeting four cardinal symptoms	Intended for use by nonpsychiatric clinicians
Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)	Algorithm targeting four cardinal symptoms	Designed for use by nursing staff in the ICU
Intensive Care Delirium Screening Checklist (ICDSC)	8-item screening checklist	Bedside screening tool for use by nonpsychiatric physicians or nurses in the ICU
Delirium Rating Scale (DRS)	Full scale of 10 items Abbreviated 7- or 8-item subscales for repeated administration	Provides data for confirmation of diagnosis and measurement of severity
Delirium Rating Scale-Revised-98 (DRS-R-98)	16-item scale that can be divided into a 3-item diagnostic subscale and a 13-item severity subscale	Revision of DRS is better suited to repeat administration
Memorial Delirium Assessment Scale (MDAS)	10-item severity rating scale	Grades severity of delirium once diagnosis has been made
Neecham Confusion Scale	10-item rating scale	Designed for use by nursing staff and primarily validated for use in elderly populations in acute medical or nursing home setting

ICU, Intensive care unit.

From Stern TA et al: Massachusetts General Hospital handbook of general hospital psychiatry, ed 7, Philadelphia, 2017, Elsevier.

Figure 1 Algorithm for evaluation of suspected mental status change in an older patient.

IM, Intramuscular; IV, intravenous; NG, nasogastric; PO, by mouth; PRN, as needed; TFTs, thyroid function tests.

Modified from Goldman L, Ausiello D [eds]: Cecil textbook of medicine, ed 24, Philadelphia, 2012, Saunders.

Etiology

Can be multifactorial; often falls into one of the following categories (Table 5):

Drugs: Benzodiazepines are the worst offenders, but other drugs such as narcotics, anticholinergics, beta-blockers, steroids, nonsteroidal antiinflammatory drugs, digoxin, cimetidine can cause delirium; also, withdrawal states such as alcohol withdrawal or benzodiazepine withdrawal can cause delirium
Infection or inflammation
Metabolic: Kidney or liver failure, thyroid, adrenal, or glucose dysregulation, anemia, vitamin deficiency such as Wernicke encephalopathy or vitamin B₁₂ deficiency, inborn metabolic errors such as porphyrias or Wilson disease
Stress: Surgery, sleep problems, pain, fever, hypoxia, anesthesia, environmental changes, fecal or urinary retention, burns
Fluids, electrolytes, nutrition (FEN): Dysregulation of calcium, magnesium, potassium, or sodium; dehydration; volume overload; altered pH
Brain disorder: CNS infection, head injury, hypertensive encephalopathy

TABLE 5 Major Causes of Delirium

Metabolic		Electrolytes: Hypo/hypernatremia, hypo/hypercalcemia, hypo/hypermagnesemia, hypo/hyperphosphatemia Endocrine: Hypo/hyperthyroidism, hypo/hypercortisolism, hypo/hyperglycemia Cardiac encephalopathy, hepatic encephalopathy, uremic encephalopathy Hypoxia and hypercarbia Vitamin deficiencies: Vitamin B₁₂, nicotinic acid, folic acid. Most notably Wernicke encephalopathy from thiamine deficiency Toxic and industrial exposures: Carbon monoxide, organic solvent, lead, manganese, mercury, carbon disulfide, heavy metals Porphyria
Toxic		Intoxication and overdose Serotonin syndrome Malignant neuroleptic syndrome Withdrawal: Alcohol, benzodiazepines, barbiturates, amphetamines, cocaine, coffee, phencyclidine, hallucinogens, inhalants, meperidine, and other narcotics Drugs: Anticholinergic, benzodiazepines, opiates, antihistamines, antiepileptics, muscle relaxants, dopamine agonists, monoamine oxidase inhibitors, levodopa, corticosteroids, fluoroquinolone and cephalosporin antibiotics, beta-blockers, digitalis, lithium, clozapine, tricyclic antidepressants, calcineurin inhibitors
Infectious		Urinary tract infection, pneumonia, sepsis, meningitis, encephalitis, Creutzfeldt-Jakob and other prion diseases
Neurological		Vascular: Ischemic stroke, intracerebral or subarachnoid hemorrhage, vasculitis Autoimmune and paraneoplastic encephalitides Neoplastic: Brain tumors, carcinomatous meningitis Seizure related: Postictal state, nonconvulsive status epilepticus Trauma: Concussion, subdural hematoma
Perioperative		Surgery: Thoracic (cardiac and noncardiac), vascular, and hip replacement, anesthetic and drug effects, hypoxia and anemia, hyperventilation, fluid and electrolyte disturbances, hypotension, embolism, infection or sepsis, untreated pain, fragmented sleep, sensory deprivation or overload
Miscellaneous		Hyperviscosity syndromes

From Jankovic J et al: Bradley and Daroff’s neurology in clinical practice, ed 8, Philadelphia, 2022, Elsevier.

Diagnosis ⬆ ⬇

Differential Diagnosis

Primary psychiatric illness
Focal syndromes
Dementia
Sundowning
Nonconvulsive status epilepticus

Remember, delirium may coexist with any of the above. Table 6 summarizes the differential diagnosis of delirium. Tables 7 and 8 describe clinical factors that help differentiate delirium and dementia from psychiatric disease. Potentially life-threatening causes of delirium are described in Table 9.

TABLE 9 Potentially Life-Threatening Causes of Delirium

CONDITION	DIAGNOSTICS	TREATMENT
Wernicke's encephalopathy	Clinical triad: Change in mental status, gait instability, ophthalmoplegia	Thiamine 500 mg IM (may see improvement over the course of hours)
Hypoxia	Oxygen saturation/ABGs	Treat etiology, give oxygen
Hypoglycemia	Blood glucose	PO/IV administration of glucose, dextrose, sucrose, or fructose
Hypertensive encephalopathy	Blood pressure	Antihypertensive medication
Hyperthermia/hypothermia	Temperature	Cooling or warming interventions
Infectious process (e.g., sepsis, bacteremia, subacute bacterial endocarditis)	Infectious disease work-up	Treat infectious agent or site
Intracerebral hemorrhage	MRI/CT	Per hemorrhage type or location
Meningitis/encephalitis	LP, MRI	Antibiotic medication, immunotherapy
Metabolic (e.g., chemical derangements, renal failure, hepatic failure, thyroid dysfunction)	Laboratory investigations	Per derangement
Poisoning/toxic reaction (e.g., environmental exposures, medications, alcohol, illicit substances)	Toxicology panel	Per toxin
Status epilepticus	EEG	Anticonvulsants and/or IV benzodiazepines

ABGs, Arterial blood gases; CT, computed tomography; EEG, electroencephalogram; IM, intramuscular; IV, intravenous; LP, lumbar puncture; MRI, magnetic resonance imaging; PO, oral (per os).

From Stern TA: Massachusetts General Hospital handbook of general hospital psychiatry, ed 7, Philadelphia, 2018, Elsevier.

TABLE 8 Special Problems in the Differential Diagnosis of Delirium ∗

Clinical Feature	Delirium	Dementias	Stroke WithWernicke Aphasia	Schizophrenia	Depression
Course	Acute onset; hours, days, or more	Insidious onset ^†; months or years; progressive	Sudden onset; chronic, stable deficit	Insidious onset, 6 mo or more; acute psychotic phases	Insidious onset, at least 2 wk, often months
Attention	Markedly impaired attention and arousal	Normal early; impairment later	Normal	Normal to mild impairment	Mild impairment
Fluctuation	Prominent in attention arousal; disturbed day/night cycle	Prominent fluctuations absent; lesser disturbances in day/night cycle	Absent	Absent	Absent
Perception	Misperceptions; illusions and pareidolias; hallucinations, usually visual, fleeting; paramnesia	Perceptual abnormalities much less prominent ^‡; paramnesia	Normal	Hallucinations, auditory with personal reference	May have mood-congruent hallucinations
Speech and language	Abnormal clarity, speed, and coherence; disjointed and dysarthric; misnaming; characteristic dysgraphia	Early anomia; empty speech; abnormal comprehension	Prominent paraphasias and neologisms; empty speech; abnormal comprehension	Disorganized, with a bizarre theme	Decreased amount of speech
Other cognition	Disorientation to time, place; recent memory and visuospatial abnormalities	Disorientation to time, place; multiple other higher cognitive deficits	No other necessary deficits	Disorientation to person; concrete interpretations	Mental slowing; indecisiveness; memory retrieval difficulty
Behavior	Lethargy or delirium; nonsystematized delusions; emotional lability	Disinterested; disengaged; disinhibited; delusions and other psychiatric symptoms	Paranoia possibly ensuing	Systematized delusions; paranoia; bizarre behavior	Depressed mood; anhedonia; lack of energy; sleep and appetite disturbances
Electroencephalogram	Diffuse slowing; low-voltage fast activity; specific patterns	Normal early; mild slowing later	Normal	Normal	Normal

^∗The characteristics listed are the usual ones and are not exclusive.

^†Patients with vascular dementia may have an abrupt decline in cognition.

^‡Patients with dementia with diffuse cortical Lewy bodies often have a fluctuating mental status and hallucinations.

From Jankovic J et al: Bradley and Daroff’s neurology in clinical practice, ed 8, Philadelphia, 2022, Elsevier.

TABLE 7 Clinical Factors That Help Differentiate Delirium and Dementia From Psychiatric Disease

Characteristic	Delirium	Dementia	Psychiatric Illness
Symptoms
Age at onset	<12 or >40 yr	Usually elderly, >50 yr	13-40 yr
Onset	Acute	Gradual or insidious	Gradual
Symptom course	Rapid, fluctuating	Stable and progressive	Stable
Duration	Days to weeks	Months to years	Months to years
Reversibility	Usually	Rarely	Rarely
History
Past medical history	Substance abuse, medical illness	Comorbid conditions of aging	Previous psychiatric history
Family history	Unusual	History of dementia	History of psychiatric illness
Physical Examination
Vital signs	Usually abnormal	Usually normal	Usually normal
Involuntary activity	May have tremors, asterixis, etc.	None unless coexistent disease	None
Mental Status
Affect	Emotional lability	Flat affect with advanced disease	Flat affect
Orientation	Usually impaired	Impaired with advanced disease	Rarely impaired
Attention	Impaired	Slow to focus	Disorganized
Hallucinations	Primarily visual	Rare	Primarily auditory
Speech	Slow, incoherent, dysarthric	Usually coherent	Usually coherent
Consciousness	Decreased to impaired	Normal (clear)	Alert
Intellectual function	Usually impaired	Impaired	Intact

From Adams JG et al: Emergency medicine, clinical essentials, ed 2, Philadelphia, 2013, Elsevier.

TABLE 6 Differential Diagnosis of Delirium

General Cause		Specific Cause
Vascular		Hypertensive encephalopathy Cerebral arteriosclerosis Intracranial hemorrhage or thrombosis Emboli from atrial fibrillation, patent foramen ovale, or endocarditic valve Circulatory collapse (shock) Systemic lupus erythematosus Polyarteritis nodosa Thrombotic thrombocytopenic purpura Hyperviscosity syndrome Sarcoid Posterior reversible encephalopathy syndrome (PRES) Cerebral aneurysm
Infectious		Encephalitis Bacterial or viral meningitis, fungal meningitis (cryptococcal, coccidioidal, Histoplasma) Sepsis General paresis Brain, epidural, or subdural abscess Malaria Human immunodeficiency virus Lyme disease Typhoid fever Parasitic (Toxoplasma, trichinosis, cysticercosis, echinococcosis) Behçet syndrome Mumps
Neoplastic		Space-occupying lesions, such as gliomas, meningiomas, abscesses Paraneoplastic syndromes Carcinomatous meningitis
Degenerative		Dementias Huntington disease Creutzfeldt-Jakob disease Wilson disease
Intoxication		Chronic intoxication or withdrawal effect of drugs, including sedative-hypnotics, opiates, tranquilizers, anticholinergics, dissociative anesthetics, anticonvulsants
Neurophysiologic		Epilepsy Postictal states Complex partial status epilepticus
Traumatic		Intracranial bleeds Postoperative trauma Heat stroke Fat emboli syndrome
Intraventricular		Normal-pressure hydrocephalus
Vitamin deficiency		Thiamine (Wernicke-Korsakoff syndrome) Niacin (pellagra) B₁₂ (pernicious anemia)
Endocrine/metabolic		Diabetic coma and shock Uremia Myxedema Hyperthyroidism Parathyroid dysfunction Hypoglycemia Hepatic or renal failure Porphyria Severe electrolyte or acid/base disturbances Cushing or Addison syndrome Sleep apnea Carcinoid Whipple disease
Autoimmune		Autoimmune encephalitides Steroid-responsive encephalopathy associated with thyroiditis (SREAT)/Hashimoto encephalopathy Systemic lupus erythematosus Multiple sclerosis
Poisoning		Heavy metals (lead, manganese, mercury) Carbon monoxide Anticholinergics Other toxins
Anoxia		Hypoxia and anoxia secondary to pulmonary or cardiac failure, anesthesia, anemia
Psychiatric		Depressive pseudodementia, catatonia, Bell mania

From Stern TA et al: Massachusetts General Hospital handbook of general hospital psychiatry, ed 7, Philadelphia, 2017, Elsevier.

Laboratory Tests

Complete blood count, electrolytes, liver function tests, ammonia, drug levels (digoxin, lithium)
Toxicology screen, urinalysis, urine culture
Thyroid function tests, vitamin B₁₂, and folate levels
Rapid plasma reagin for syphilis, blood, urine, and spinal fluid culture
Arterial blood gas
Lumbar puncture is mandatory when cause of delirium is not obvious

Imaging Studies

Consider head CT (to look for bleed, trauma, tumor, atrophy, dementia, stroke)
Chest radiograph (to look for tumor, infection)

Electroencephalogram

To exclude seizure, confirm diagnosis of metabolic encephalopathy

Treatment ⬆ ⬇

Nonpharmacologic Therapy

The most important consideration is to keep the patient safe by using a variety of methods, including frequent reorientation.
A quiet, restful, simplified environment with cues to time and location such as clock or calendar is helpful, as well as consistent staff providing both personal and medical care. If possible, encourage familiar family members and friends to keep the patient company.
Early mobilization and minimized use of physical restraints (use of physical restraints if necessary to ensure safety).
Visual and hearing aids for patients with these impairments.

Acute General Rx

Reverse any treatable cause, such as volume repletion for patients with dehydration, antibiotics for urinary tract infection.
Antipsychotic agents should not be used routinely for preventing or treating delirium. Pharmacologic treatment with antipsychotic agents should be initiated only when symptoms are severe, dangerous, or cause significant distress to the patient. In general these agents are similarly effective and the choice among them is usually made on the basis of side effects. Haloperidol is the least sedating but has a high risk of extrapyramidal side effects; quetiapine has the fewest side effects but is highly sedating.
Haloperidol can be used with caution to control agitation, with doses ranging from 0.25 to 2 mg IM/IV twice daily, repeating the dose every 20 to 30 min until patient has calmed and using lower doses for the elderly. An IV haloperidol protocol used at Massachusetts General Hospital in agitated delirious patients is described in Table E10.
Most antipsychotics can prolong the QT interval and increase the risk of torsades de pointes. The effect is greatest with IV haloperidol and least with aripiprazole. Aripiprazole is available in tablets, solution, and injection. Starting dose is 1 mg twice a day.
Risperidone 0.5 mg twice daily (off-label use, non-FDA approved) can also be used with caution with a slow increase to desired dose, not to exceed 1.0 to 2.0 mg.
Avoid benzodiazepines and meperidine. Drug toxicity accounts for approximately 30% cases of delirium.

TABLE E10 Massachusetts General Hospital Protocol for IV Haloperidol in Agitated Delirious Patients

Check Pre-Haloperidol QTc Interval

If QTc >450 ms, proceed with care.
If QTc >500 ms, consider other options.

Check Potassium and Magnesium, and Correct Abnormalities

Aim for potassium >4 mEq/L, magnesium >2 mEq/L.

Give Dose of Haloperidol (0.5-10 mg) Based on Level of Agitation and Patient's Age and Size

Goal is to have patient calm and awake.
Haloperidol precipitates with phenytoin and heparin; flush line before giving haloperidol if these agents have been used in the same intravenous tubing.
Wait 20-30 min. If patient remains agitated, double dose.
Continue to double dose every 30 min until patient is calm.

Follow QTc Interval to Ensure That QTc Is Not Prolonging

If QTc increases by 25% or becomes >500 ms, consider alternative treatments.

Once Effective Dose Has Been Determined, Use That Dose for Future Episodes of Agitation

Depending on likely course of delirium, may schedule haloperidol or give on as-needed basis.
For example, may divide previous effective dose over next 24 h, giving every 6 h.
Or may simply give effective dose as needed for agitation.
Consider small dose at night to regulate sleep-wake cycle in all delirious patients.

From Stern TA: Massachusetts General Hospital handbook of general hospital psychiatry, ed 7, Philadelphia, 2018, Elsevier.

Chronic Rx

Delirium is not a chronic condition; if assessing a more long-term mental status change, consider other diagnoses.

Disposition

Requires frequent monitoring often necessitating hospital level of care to ensure safety and assess etiology.

Referral

Consider neurologic or psychiatric consultation if not improved in several days or in complicated cases.

Pearls & Considerations ⬆ ⬇

Comments

Although benzodiazepines are frequently used in hospitalized patients for sedation and are the mainstay of therapy for alcohol withdrawal, they must be used with caution in the elderly because they can have a paradoxical effect on agitation.

TABLE 11 Priorities (Consensus, Evidence-Based, and Speculative) for the Prevention, Management, and Advancement of the Treatment of Delirium

Community-Based Prevention	Hospital-Based Prevention	Hospital-Based Management	Postdischarge Management	Clinical Research Opportunities
Hospital avoidance strategies	Implementation of basic standards (e.g., screening for delirium) Minimization of iatrogenesis ∗	Implementation of basic standards (e.g., review of medications)∗	Responsive, proportionate, and holistic follow-up ∗	Pragmatic research into optimizing care delivery
Identification and management of frailty	Multicomponent interventions to address frailty ^† Reorientation ^† Nutrition ^† Multidisciplinary care ∗ Physiologic correction ^† Sensory optimization ^† Minimization of ward transfers ∗ Avoidance of polypharmacy ^†	Multicomponent interventions to address frailty ∗ Reorientation ∗ Nutrition ∗ Multidisciplinary care ∗ Physiologic correction ∗ Sensory optimization ∗ Minimization of ward transfers ∗ Reduction of drug burden ∗	Identification and management of frailty Reduction and cessation of antipsychotics	The interaction between frailty, interventions to ameliorate frailty, and delirium Transference from basic science models to trials of newer therapies Validation of delirium models using advanced imaging
Pleiotropic interventions (e.g., exercise/nutrition)	Monitor and promote early mobilization ^†	Monitor and promote early mobilization ∗	Review of the primary triggers for delirium and other state variables (e.g., mobility)	Delirium, mobility, and response to physical therapy
Early diagnosis and management of dementia	Screening for dementia ∗	Screening for delirium resolution and residual cognitive impairment	Screening for subsyndromal delirium or dementia ∗	The interaction between dementia, including non-Alzheimer dementia, and delirium
Education of nursing home facilities and staff	Education of nursing and medical staff ∗	Education of medical and nursing staff ∗	Caregiver support and education	The role of education of nonmedical staff, families,^‡ and general public using multimedia solutions
Integrated geriatric care for planned major surgery	Targeted drug treatments (e.g., melatonin for sleep disturbance)^† Family-based screening/ reorientation ^†	Delirium units Supported early discharge Family-based screening/ reorientation ∗ Management in the nursing home with CGA capability	Adaptive and versatile methods of follow-up such as telemedicine	The role of novel and targeted interventions and models of care supported by assistive technologies
Public health awareness	Audit of care and cycle of care improvement ∗	Audit of care and cycle of care improvement ∗	Public health awareness/NGO engagement	Development of key indicators in the management of delirium

CGA, Comprehensive geriatric assessment; NGO, nongovernmental organization.

^∗Consensus role.

^†Evidence-based role.

^‡Speculative role.

From Fillit HM: Brocklehurst’s textbook of geriatric medicine and gerontology, ed 8, Philadelphia, 2017, Elsevier.

Prevention (Table 11

Avoid polypharmacy as much as possible.
Optimize chronic medical conditions.
Provide frequent reorientation and a soothing environment for high-risk patients (e.g., lights on during the day, off at night; open curtains during the day so patient can see the weather).
In patients over 70 without dementia, regular exercise has been associated with lower risk for developing delirium, and early return to physical activity can improve outcomes in ill patients.

Patient & Family Education

Inform about the above preventive techniques, especially polypharmacy risks.

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section name header

Basic Information ⬇

Diagnosis ⬆ ⬇

Treatment ⬆ ⬇

Pearls & Considerations ⬆ ⬇

Suggested Readings ⬆