Thanks to our awesome pall care/geriatrics team for a great talk on delirium, with a focus on the elderly. This was a great reinforcement to last week’s grand rounds on inpatient delirium management!
Delirium is defined by certain key features
- Acute onset
- Impaired cognition with disorganized thought
- Other supporting symptoms: sleep/wake disturbance, emotional lability, perceptual disturbances
Delirium differs from dementia in two key ways: 1) delirium is acute and waxes and wanes and 2) is characterized by inattention.
Here’s a recent JAMA table highlighting key differences:
Common triggers of delirium in the hospital
So how to manage delirium once you’ve identified it? (…unfortunately it turns out there’s not great evidence for many of the things we commonly reach for)
Non-pharmacologic: redirection, early mobilization, removing restraints/catheters/tele, environmental cues (blinds up during day, dark, quiet room at night)
Pharmacologic: melatonin >> antipsychotics
- For melatonin, you can start at 3mg and uptitrate. It has few downsides!
- It has been suggested in multiple studies (including a meta-analysis) to be of benefit in delirium prevention in hospitalized patients
- If you have to use antipsychotics, start low (ex: 0.5mg haldol), go slow and try to use only in the very short term
- there is no guideline for switching between antipsychotics, so unclear benefit to doing so
Antipsychotics, on the other hand, are increasingly falling out of favor. Atypical antipsychotics even carry a black box warning because they may increase mortality in the elderly.
This article suggested that even typical/conventional antipsychotics increased short-term mortality in the elderly: “…patients for whom conventional agents were prescribed had a 37% higher, dose-dependent risk of death in the short term than those for whom atypical agents were prescribed. To place this magnitude of risk in perspective, only cancer, congestive heart failure, and HIV infection conferred greater adjusted risks in our analyses.”
Delirium management summary table