Clinical management and prevention of delirium

Delirium affects over one-third of hospitalized elders. Yet it remains under-recognized and often inappropriately evaluated and managed. This contribution summarizes the key steps in delirium management and prevention. The first step is accurate diagnosis. This requires periodic structured mental status screening, and application of a diagnostic algorithm such as the Confusion Assessment Method. Knowledge of the patient's baseline mental status is imperative. The second key step is evaluation; all delirious patients require a thorough evaluation for reversible causes and contributors, including a careful history, physical examination, detailed medication review and selected laboratory testing. The final step is management, which involves the correction of reversible causes and contributors identified above, prevention of complications of delirium, management of behavioural problems using the least toxic means, and support of the functional needs of the patient. Delirious patients are vulnerable and require an intensive interdisciplinary effort to maximize the likelihood of a favourable outcome. Pharmacological intervention should be reserved for key target symptoms that are not controllable using non-pharmacological strategies. Low-dose, high-potency antipsychotics are the treatment of choice. Preferable to managing delirium is preventing it from developing in the first place, which can be accomplished using a proactive, multifactorial protocol that addresses key risk factors in the development of delirium. More research is needed on how to optimally manage this common, morbid and costly syndrome.