Evaluation and Management of Delirium

Abstract

Delirium, sometimes referred to as encephalopathy, is an acute confusional state that is both common in hospitalized patients and associated with poor outcomes. For patients, families, and caregivers, delirium can be a traumatic experience. While delirium is one of the most common diagnoses encountered by the consulting neurologist, the majority of the time it will have been previously unrecognized as such by the care team. Neurologic syndromes such as dementia or aphasia can either be misdiagnosed as delirium or may coexist with it, necessitating careful neurologic assessment. Once the diagnosis of delirium has been established, a careful evaluation for predisposing and precipitating factors can help uncover modifiable contributors, which should be addressed as part of a multicomponent, primarily nonpharmacologic intervention. Importantly, delirium management, which begins with comprehensive prevention, should emphasize the humanity of the delirious patient and the challenges of caring for this vulnerable population. When considered, delirium represents an important opportunity for the neurologist to substantially enhance patient care.

Barriers to healthcare professionals recognizing and managing delirium in older adults during a hospital stay: A mixed‐methods systematic review

“…Some healthcare professionals were less familiar with specific risk factors for delirium, e.g., vision impairment, being male, a dementia diagnosis and having an internal device such as a urinary catheter (Hare et al, 2008;Meako et al, 2011;Rosado et al, 2019). Some healthcare professionals did not know if their hospital organization had a delirium management protocol in place and in two studies participants were unsure about the treatment pathway (Limpawattana et al, 2018;Ryan & Milligan, 2017). Doctors reported that their nursing colleagues lacked knowledge about delirium care, especially non-pharmacological interventions, and that this contributed to an increase in the use of pharmacological interventions or restraint (Van de Steeg et al, 2014).…”

“…Some healthcare professionals did not know if their hospital organization had a delirium management protocol in place and in two studies participants were unsure about the treatment pathway (Limpawattana et al., 2018; Ryan & Milligan, 2017). Doctors reported that their nursing colleagues lacked knowledge about delirium care, especially non‐pharmacological interventions, and that this contributed to an increase in the use of pharmacological interventions or restraint (Van de Steeg et al., 2014).…”

“…Four studies reported that CPD on the topic resulted in healthcare professionals feeling more confident and competent in identifying and managing delirium in the older person (Akinjogbin et al., 2020; Fick et al., 2018; Kang et al., 2017; Rosen et al., 2013). Healthcare professionals in fifteen studies requested more delirium training to include consequences of undiagnosed delirium, assessment tools, hypoactive delirium, delirium superimposed on dementia and other underlying cognitive impairments and care management (Akintade et al., 2011; Alhaidari & Allen‐Narker, 2017; Campioni‐Norman & Vizcaychipi, 2017; Emme, 2020; Hosie et al., 2015; Kai‐Chung Wong et al., 2018; Kang et al., 2017; LaMantia et al., 2017; Merkin et al., 2014; Randles et al., 2018; Rosen et al., 2013; Ryan & Milligan, 2017; Schonnop et al., 2022; Van de Steeg et al., 2014; Wang & Mentes, 2009). A lack of CPD on the topic meant that healthcare professionals found it difficult to administer and interpret delirium assessment tools (Alhaidari & Allen‐Narker, 2017; Hosie et al., 2015; Kai‐Chung Wong et al., 2018; Kang et al., 2017; Rice et al., 2011).…”

Anesthesia and surgery-induced elevation of CSF sTREM2 is associated with early cognitive dysfunction after thoracoabdominal aortic dissection surgery

“…Briefly, Z-score was calculated by the following way: ([change score] individual -[mean change score])/(standard deviation change score total ) [ 25 , 26 ]. The diagnosis of postoperative delirium (POD) employed CAM-ICU on postoperative days 3 and 7 [ 27 , 28 ].…”

Medication safety in nursing home patients

“…However, the more robust approach to behavioural dysregulation, whether caused by delirium or other factors, should involve investigation of and mitigation of precipitating causes. Indeed, ongoing research into the management of delirium recognises the key role of diagnosing the underlying cause of the patient’s acute confusional state and treating the underlying cause, with support of other non-pharmacological interventions before new medications are initiated 27 28…”