Evaluation and management of delirium in hospitalized older patients

Delirium is common in hospitalized older patients and may be a symptom of a medical emergency, such as hypoxia or hypoglycemia. It is characterized by an acute change in cognition and attention, although the symptoms may be subtle and usually fluctuate throughout the day. This heterogeneous syndrome requires prompt recognition and evaluation, because the underlying medical condition may be life threatening. Risk factors for delirium include visual impairment, previous cognitive impairment, severe illness, and an elevated blood urea nitrogen/serum creatinine ratio. Interventions that have been shown to reduce the incidence of delirium in at-risk hospitalized patients include repeated reorientation of the patient to person and place, promotion of good sleep hygiene, early mobilization, correction of dehydration, and the minimization of unnecessary noise and stimuli. The treatment of delirium centers on the identification and management of the medical condition that triggered the delirious state. Nonpharmacologic interventions may be beneficial, but antipsychotic agents may be needed when the cause is nonspecific and other interventions do not sufficiently control symptoms such as severe agitation or psychosis. Although delirium is a temporary condition, it may persist for several months in the most vulnerable patients. Patient outcomes at one year include a higher mortality rate and a lower level of functioning compared with age-matched control patients.