The evaluation and management of the acutely agitated elderly patient

Delirium is an organic mental syndrome defined by a global disturbance in consciousness and cognition, which develops abruptly and often fluctuates over the course of the day. It is precipitated by medical illness, substance intoxication/withdrawal or medication effect. Delirium is associated with significant morbidity and mortality, and is a leading presenting symptom of illness in the elderly. Elderly patients with altered mental status, including agitation, should be presumed to have delirium until proven otherwise. The clinical manifestations of delirium are highly variable. A mental status evaluation is crucial in the diagnosis of delirium. Medical evaluation and stabilization should occur in parallel. Life-threatening etiologies including hypoxia, hypoglycemia and hypotension require immediate intervention. The differential diagnosis of etiologies of delirium is extensive. Patients with delirium need thorough evaluations to determine the underlying causes of the delirium. Pharmacological agents should be considered when agitated patient has the potential to harm themselves or others, or is impeding medical evaluation and management. Unfortunately, the evidence to guide pharmacologic management of acute agitation in the elderly is limited. Current pharmacologic options include the typical and atypical antipsychotic agents and the benzodiazepines. These therapeutic options are reviewed in detail.