Management of delirium in older adults: challenges and opportunities

Abstract

Management of delirium in older adults: challenges and opportunitiesDelirium is a vexing clinical problem in hospitalized older adults. Despite the established association between delirium and death, morbidity, institutionalization, and patient distress (Siddiqi et al., 2006), few high-quality studies examining the management of delirium in older adults exist. Delirium management strategies can be broadly divided into those addressing prevention or treatment, as well as pharmacological and non-pharmacological modalities. Additional considerations include peri-operative and post-operative delirium management and management of delirium in the intensive care unit (ICU).Among hospitalized older adults, multicomponent non-pharmacological interventions have the best evidence for primary prevention of delirium. Such strategies, ideally delivered by an interdisciplinary team, include early mobilization, pain management, infection prevention, use of vision and hearing aids, avoidance of sleep disruption, adequate hydration and nutrition, re-orientation, cognitive stimulation, and review of psychoactive medications. A meta-analysis of 14 interventional studies found that implementation of the Hospital Elder Life Program (Inouye et al., 1999), a multicomponent interdisciplinary intervention, reduced the risk of incident delirium by 53% (OR 0.47 [95% CI, 0.38-0.58]) among hospitalized, non-ICU patients age 65 years and older (Hshieh et al., 2015). On the other hand, there is no high-quality evidence supporting the use of multi-component interventions to treat delirium once it has developed.Despite widespread use of pharmacological treatments, particularly antipsychotics, to manage delirium in hospitalized patients, most studies show no benefit in the use of medications to either prevent or treat delirium in hospitalized older adults (outside of specific cases such as alcohol-withdrawal delirium) (Oh et al., 2017). Medications studied in randomized, placebo-controlled trials for either prevention or treatment of delirium in older adults include haloperidol, atypical antipsychotics (aripiprazole, risperidone, olanzapine, quetiapine), melatonin, ramelteon, gabapentin, pregabalin, ondansetron, donepezil, methylprednisolone (at anesthetic induction), and dexmedetomidine (in the ICU and peri-operatively) (Oh et al., 2017). Only the

Pharmacotherapy in geriatric psychiatry: what we know and what we need to know

“…The authors conclude that there is no high-quality evidence supporting the use of anticonvulsants in preventing or treating delirium in hospitalized older adults. Fortunately, several initiatives are currently underway to standardize delirium research (Bingham and Flint, 2022). Some multicomponent prevention studies have suggested useful strategies for delirium management.…”