Delirium in the elderly

Delirium is a state of disturbed consciousness and attention and cognition or perception, which develops acutely, fluctuates during the course of the day, and is attributable to a physical disorder. This syndrome is the focus of increasing attention in light of emerging evidence of its enormous impact in human suffering as well as patient care costs. As currently conceptualized, delirium is a threshold phenomenon in which systemic and cerebral insults are cumulative and, in most cases, are multifactorial in origin. Because delirium results from an underlying medical condition, its prognosis is dependent largely on how quickly that condition is identified and appropriately treated. A basic algorithm for initial delirium management is reviewed, which includes discontinuing noncritical medications, instituting close observation, monitoring vital signs and fluid intake and output, obtaining a complete history, performing initial laboratory studies to determine the causes, implementing environmental and psychosocial interventions, and instituting pharmacologic treatment as indicated for agitation and psychosis. The pharmacologic treatment of choice is an antipsychotic of the butyrophenone class. Benzodiazepine use is reserved for the specific treatment of alcohol and sedative withdrawal, and for adjunctive use with antipsychotic agents in treatment-refractory cases. There is growing evidence that the cognitive impairment of delirium is not entirely reversible in all patients, and it may be that delirium represents a time of significant risk for progression of underlying dementia. Preventive measures discussed in the text are, therefore, of particular importance in this population.