Clinical management and prevention of delirium

Delirium affects more than one-third of hospitalized elderly patients. Yet, it remains under-recognized and is often inappropriately evaluated and managed. This article summarizes the key steps in delirium management and prevention. The first key step is accurate diagnosis. This requires periodic 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. 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, management of behavioural problems using the least toxic means, prevention of complications, and support of the functional needs of the patient. Pharmacological intervention should be reserved for key target symptoms that are not controllable using behavioural approaches. Low-dose, high-potency antipsychotics, such as haloperidol, are the treatment of choice. Atypical agents are used frequently, but are equivalent to haloperidol. Several models of care for delirium have been tested. Proactive strategies have been demonstrated to reduce delirium incidence, severity, and duration. Once delirium has developed, intervention is less successful. More research is needed regarding how to optimally manage this common, morbid, and costly syndrome.