Treatment of Delirium in Older Persons: What We Should Not Do!

Abstract

The presentation of common acute diseases in older age is often referred to as “atypical”. Frequently, the symptoms are neither single nor tissue related. In most cases, the onset of symptoms and diseases is the expression of a diminished reserve with a failure of the body system and imbalance of brain function. Delirium is one of the main devastating and prevalent atypical symptoms and could be considered as a geriatric syndrome. It encompasses an array of neuropsychiatric symptoms and represents a disarrangement of the cerebral function in response to one or more stressors. The most recent definition, reported in the DSM-V, depicts delirium as a clear disturbance in attention and awareness. The deficit is to be developed in a relatively short time period (usually hours or days). The attention disorder must be associated with another cognitive impairment in memory, orientation, language, visual-spatial or perception abilities. For the treatment, it is imperative to remove the potential causes of delirium before prescribing drugs. Even a non-pharmacological approach to reducing the precipitating causes should be identified and planned. When we are forced to approach the pharmacological treatment of hyperactive delirium in older persons, we should select highly cost-effective drugs. High attention should be devoted to the correct balance between improvement of psychiatric symptoms and occurrence of side effects. Clinicians should be guided in the correct choice of drugs following cluster symptoms presentation, excluding drugs that could potentially produce complications rather than advantages. In this brief point-of-view, we propose a novel pharmacological flow-chart of treatment in relation to the basic clusters of diseases of an older patient acutely admitted to the hospital and, in particular, we emphasize “What We Should Not Do!”, with the intention of avoiding possible side effects of drugs used.

Delirium in COVID-19: epidemiology and clinical correlations in a large group of patients admitted to an academic hospital

“…This situation may pose further diagnostic dilemmas, since the clinical manifestations of delirium superimposed on dementia are sometimes difficult to distinguish from the usual symptoms of dementia, especially in clinical contexts, where the personnel lacks geriatric training [26,27]. Moreover, the treatment of delirium superimposed on dementia in COVID-19 patients should be evaluated carefully, since many sedative drugs may contribute to worsen the respiratory failure and interact with QT-prolonging drugs, such as hydroxychloroquine and azithromycin, that are often prescribed for the treatment of SARS-COV-2 infection [28].…”

Levels of S100 calcium binding protein B (S100B), neuron-specific enolase (NSE), and cyclophilin A (CypA) in the serum of patients with severe craniocerebral injury and multiple injuries combined with delirium transferred from the ICU and their prognostic value

“…The progress of basic research and clinical research in recent years has shown that interventions for such patients are extremely important. Dynamic observation and accurate and effective treatment must be adopted to reduce the mortality rate (15,16). The S100B protein is an acidic calcium-binding protein, which is mainly found in astrocytes and oligodendrocytes of the central nervous system, and Schwann cells of the peripheral nervous system.…”

Improving the care of older patients during the COVID-19 pandemic

“…For older patients who need hospitalization, we suggest the creation of specific areas within the hospitals, to guarantee treatments tailored for frail patients. For instance, it is well known that non-pharmacological approaches are more effective than pharmacological ones in the prevention and treatment of hyperactive delirium [28].…”