Let’s start off our discussion about managing delirium in the elderly with a patient case study:

An 84-year-old female named JD was admitted to the hospital.

JD has a four-year history of cognitive decline, where she experiences trouble with memory and understanding.

Because of this, she sometimes needs assistance from her caregiver to perform daily tasks.

While in the hospital for another condition, she experiences a fall, witnessed by a staff member, who was unable to assist her in time.

The providers then assess JD completely for fractures and internal injuries and bleeding, including the standard physical examination, laboratory tests, and scans of her head.

The doctors find no issue with her and are preparing to clear her medically. At this point, she starts demonstrating signs of disorientation, hallucinations, and confusion.

The doctors suspect that JD may be suffering from delirium. They prepare her for prompt intervention and treatment.

Now that we have set the stage for our discussion, let’s go in-depth into delirium in the elderly, and then we are going to return to JD at the end of this post to see how we can help her.

What causes delirium in the elderly?

As you age, you may start having trouble with memory and understanding.

Occasional slippage with recalling someone’s name, or remembering to take your medication, may sometimes occur. Sometimes, family members notice this.

As long as it does not happen too often and your cognition, quality of life, Activities of Daily Living (ADLs – bathing, dressing, etc), or Instrumental Activities of Daily Living (IADLs – planning vacation, balancing a checkbook, etc) are not affected, there is nothing to worry about.

Unfortunately your risk for developing delirium increases as you age, and in the setting of many clinical situations.

Therefore, it is important to note that there is no one single cause for the development of delirium in the elderly.

For example, time spent in the intensive care unit, acute illness, sensory impairments, sleep deprivation, alcohol abuse, severe illness, new medications, head trauma, electrolyte imbalance, urinary retention, and many other precipitating factors can be associated with the development of delirium in the elderly.

There is much to talk about this serious medical problem – let’s dive into it in detail.

Delirium refers to when you suddenly experience short-term confusion and fall into an acute confused state.

With the development of delirium, you may have changes in your awareness, mental state, and memory.

This sudden change in mental function requires medical attention.

As I mentioned above, Delirium in the elderly is common.

Between 10 to 15 percent of older adults who present to the emergency department are experiencing delirium.

That rate can increase up to 50 percent for older adults undergoing high-risk surgeries.

Delirium and dementia are two conditions that involve decreased cognitive function.

However, delirium in the elderly differs in that it happens suddenly and can be reversible.

Dementia is progressive and not reversible. The conditions often exist together, though, as they are interrelated.

Likewise, individuals with dementia have an increased chance of experiencing delirium, especially if they get sick or have a worsening of an existing condition.

Certain things increase an individual’s risk of having delirium and things that can worsen this problem.

As many factors affect delirium, usually a few things need to occur at once.

Someone at high risk of delirium will need minimal triggers to experience delirium. Someone at low risk of delirium will require more triggers to experience delirium.

Risk factors for delirium
Conditions associated with older adults	Dementia Falls A history of delirium Malnutrition Depression
Other medical conditions	Infection Surgery Alcohol abuse Lung, kidney, liver, heart, or brain disease Terminal illness Chronic pain Infection Urinary or digestive problems
Individual characteristics	Male Over the age of 65
Environmental factors	Social isolation Inactivity Sleep deprivation ICU admission
Other factors	Medication Surgery Dehydration Fracture [3]

What are the three sub-types of delirium in the elderly?

There are three types of delirium in the elderly: hyperactive, hypoactive, and mixed delirium.

Older patients commonly experience hypoactive delirium; however, mixed delirium is the most common.

The common features of each are summarized in the table below:

3 sub-types of delirium

3 Sub-Types of Delirium
Hyperactive	Restlessness, agitation, hypervigilance (paranoia), impatience, anger, wandering, singing, swearing, laughing, loud or fast speech, uncooperativeness, quick movements, nightmares, euphoria, easy startling, going on verbal tangents, easily distracted, persistent thoughts
Hypoactive	Inattentiveness, Unusual drowsiness and lethargy, Reduced motor activity/movement, staring into space, social and emotional withdrawal.
Mixed	Occurs when a patient experiences symptoms of both hyperactive and hypoactive delirium [2]

 

What are the signs and symptoms of delirium in the elderly?

Somebody’s delirium symptoms will depend on the kind of delirium you experience, as noted above. The common signs of delirium that should prompt evaluation include:

Signs and Symptoms of Delirium

Signs and Symptoms
Agitation Restlessness Confusion Acting combative	Disorientation Hallucinations Acting emotional Being disruptive	Being resistant to care Being hard to understand Lethargy/Drowsiness Inattentiveness "Staring into space"

 

How is delirium diagnosed?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) outlines five criteria that must be met to diagnose someone with delirium. These include:

1. Changes in attention (e.g., a decreased ability to maintain focus) and awareness (e.g., confusion about sense of self and surroundings)
2. Changes to mental status (e.g., trouble with memory, language, etc.)
3. The changes seen in numbers 1 and 2 are not due to a pre-existing mental disorder or cognitive impairment
4. Mental changes that occur suddenly (usually hours to a few days) that fluctuate
5. Evidence that delirium is due to an underlying medical condition, drug, toxin, etc.

If these five criteria are met, you can assume someone is experiencing delirium.

Healthcare professionals can quickly screen for delirium in the elderly using the Confusion Assessment Method (CAM) screening tool.

As in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria, the CAM looks for distinct features to confirm the diagnosis of delirium.

The checklist includes:

1. Quick onset of delirium and fluctuations in symptoms
2. Inattention
3. Disorganized thought
4. Changes in the level of consciousness

If the patient checks off both one and two, and either three or four, they have a positive CAM result.

This means the patient is likely experiencing delirium.

Why do physicians misdiagnose or miss delirium in the elderly?

Clinicians can sometimes misdiagnose delirium or not diagnose it at all.

Because providers miss the signs of delirium, they may continue to prescribe drugs that could be contributing to the problem. A few reasons why doctors may miss a delirium diagnosis include:

• Delirium being confused or mistaken for dementia
• The misconception that delirium only includes behaviors such as hallucinations or agitation and not hypoactive symptoms such as disinterest and inactivity
• Not understanding the fluctuating course of delirium and thinking an absence of symptoms means the patient is “normal”
• Not understanding that delirium symptoms could be indicative of a serious underlying condition

 

What Medications Can Cause Delirium?

Several medications can contribute to the delirious state. These drugs are categorized below based on their high or lower risk for causing delirium.

Medications that can cause delirium

High Risk	Moderate or low risk
Benzodiazepines Anticholinergic medications (e.g., antipsychotic medications, muscle relaxants, and antihistamines) Dopamine agents (e.g., levodopa, pramipexole, etc.) Meperidine (Demerol)	Blood pressure medications Anticonvulsants Antibiotics Steroids Sedatives/hypnotics Nonsteroidal anti-inflammatory drugs (NSAIDs) Certain antidepressants Antivirals Anti-nausea drugs Opioids [3]

Additionally, “polypharmacy” can also contribute to delirium in the elderly.

Polypharmacy is when an individual is taking several medications at once.

Polypharmacy is prevalent in older adults, as older individuals are more likely to be managing multiple medical conditions that need treatment.

Though these medications may be needed to manage your diseases, they can also have adverse effects, causing falls and delirium.

For example, if you take more than four medications, you have an increased chance of falling and getting injured.

This risk increases the more medications that you are on.

Because of the risks associated with polypharmacy, providers should frequently evaluate an older adult’s list of medications.

This assessment should look for drugs that can cause delirium or unnecessary therapy.

Additionally, providers should implement conservative prescribing. Conservative prescribing promotes safe and appropriate medication use through a variety of methods.

These include:

• Trying non-pharmacologic therapies and lifestyle changes before prescribing medications
• When medication is needed, start with one drug at a time at a low dose if possible
• Continuous monitoring for drug reactions and unwanted side effects

 

How Does Delirium Affect Older Adults Specifically?

As you grow in age, the likelihood that you have one or more chronic conditions increases.

Additionally, it is not uncommon to have an injury or other medical condition in old age.

Seniors may also be moving to and from different environments, such as from the home, the hospital, or assisted living facilities.

These factors, together or alone, can predispose seniors to delirium.

Can delirium in the elderly be fatal?

Delirium is a serious condition. One study found that in hospitalized older adults, delirium increases their risk of death.

In fact, the death rate for hospitalized patients experiencing delirium is between 10 and 26 percent.

A patient’s prognosis depends on how long delirium lasts and what kind of delirium they experience.

For example, hypoactive and longer-lasting delirium have worse outcomes.

Delirium does not just increase an individual’s risk of death; it also leads to poorer outcomes.

Delirium can increase the risk of institutionalization (placement in a nursing home, etc) by over 2-fold and the risk of dementia by over 12-fold.

Delirium is also associated with a decrease in physical function. On average, patients lose the ability to perform one activity of daily living (ADL) for each episode of delirium.

How can you prevent delirium in the elderly?

The best way to handle delirium involves avoiding it altogether, if possible. Modifying a few potential risk factors can lower one’s risk of delirium.

For example, if you have a scheduled surgery, your healthcare provider should perform a mental status test to understand your baseline mental functioning.

If you have risk factors for delirium, your doctor should pay close attention to your cognitive state throughout your length of hospital stay.

Your doctor can also review all of your medications and stop or hold the ones that increase your risk of developing delirium.

There are several ways to help prevent delirium, specifically in older adults that are in the hospital.

These include:

• Getting you up and moving as soon as it is safe
• Making your environment comfortable, such as having a normal sleep schedule and reducing noise disruptions
• Staying hydrated with plenty of fluids
• Helping orient yourself to where you are using windows, clocks, and calendars
• Minimizing the use of certain medications
• Allowing you to use your glasses, hearing aids, or dentures

Can delirium be cured? How long does it last?

Healthcare providers treat delirium as a medical emergency, as it requires immediate medical attention and intervention.

While serious, delirium in the elderly is reversible through a combination of medication, supportive care, and treatment of underlying conditions.

Though delirium can be “cured”, delirium can last anywhere from hours to weeks to even months.

Management of delirium in the elderly

Delirium in the elderly can be treated with both non-pharmacologic and pharmacologic therapy. Non-pharmacologic therapy should be utilized first, if possible.

However, if patients are putting their own or others’ safety at risk, medications can be started.

No matter how delirium is managed, it is important to closely monitor an individual who is delirious.

Non-medication management of delirium in the elderly

If there is an underlying condition that is causing delirium, it is best to manage that condition.

Treating the underlying cause should hopefully lessen delirium symptoms in the elderly.

To manage delirium without medication, you would take many of the same measures that you would to prevent delirium.

For example, a large part of delirium involves confusion about one’s surroundings. Therefore, minimizing environmental stressors can be helpful.

To do so, you may try:

• Avoiding switching up your environment (e.g., moving rooms, having a lot of staff turnover)
• Having friends and family frequently visit
• Maintaining normal routines for meals, activities, and tests
• Shutting the lights off at night
• Decreasing noise
• Moving around frequently (e.g., taking walks)

The hustle and bustle of the hospital are sometimes what cause delirium.

Therefore, an individual’s delirium symptoms will oftentimes resolve upon returning home.

This is important to remember so that a delirious individual is not sent to a nursing home when it is not actually necessary.

If delirium is serious and putting someone’s safety at risk, providers may implement physical restraints.

For example, a person in the hospital that is delirious may attempt to remove their catheters or oxygen.

While restraints may keep this person safe short term, it is not recommended for extended periods of time and should be a last resort. This is because restraints:

• Do not actually have evidence of preventing falls or injury
• Pose a strangling or injury risk
• Promote immobility, increasing one’s risk for complications (older adults need to MOVE, MOVE, MOVE!)
• May increase agitation and irritability

Medication Management Of Delirium

Medication is usually not necessary to manage delirium in the elderly.

Additionally, there are various risks associated with medication use with delirium, which will be discussed later.

In serious cases of delirium, medications can be used. Usually, this is when someone is experiencing hyperactive delirium.

Symptoms of hyperactive delirium may put the patient’s safety at risk or prevent them from receiving adequate medical treatment.

Some providers may also give medication to individuals with hypoactive delirium.

There are no medications that are currently approved by the FDA to treat delirium.

However, there are multiple drugs that can be used off-label that may be effective. Typically, haloperidol is first-line to treat delirium.

This is because there is a large body of evidence supporting its use in delirium compared to other agents like antipsychotics.

Atypical antipsychotics (work more on serotonin vs dopamine) are not recommended as initial therapy.

Melatonin and melatonin agonists (e.g., Ramelteon) can also be used.

The table below summarizes potential medications that can be used for managing delirium in the elderly.

Pharmacological therapy for delirium [3,4]

Drug	Dose	Side effects
Antipsychotics
Haloperidol (Haldol)	0.5 to 1 mg twice daily by mouth or into the muscle as needed or standing dose regimen (max dose not established)	Extrapyramidal symptoms (EPS – involuntary movements, tremors, muscle contractions), QT prolongation and Torsades de Pointes (heart problems – increases risk of sudden death), increased all-cause death in elderly people with dementia
Atypical antipsychotics
Quetiapine (Seroquel)	12.5 mg three times daily with 25 mg at bedtime as needed or standing dose regimen (max dose 800 mg)
Olanzapine (Zyprexa)	2.5 mg twice daily with 2.5 mg at bedtime as needed or standing dose regimen (max dose 20 mg )
Risperidone (Risperal)	0.5 mg twice daily as needed (max dose 8 mg)
Ziprasidone (Geodon)	10 mg twice daily as needed (max dose 160 mg)
Aripiprazole (Abilify)	5 mg twice daily as needed (max dose 30 mg)
Benzodiazepines
Lorazepam (Ativan)	0.5 to 1 mg every four hours as needed	Trouble breathing, oversedation, confusion
Other
Melatonin	1 to 3 mg at night as needed (max dose 10 mg)	Daytime sleepiness
Valproic acid (anti-seizure drug, mood stabilizer)	125 to 250 mg three times daily as needed (max dose 60 mg /kg)	Stomach pain, diarrhea, headache, drowsiness, weight gain, monitor liver enzymes, platelets, and ammonia

What are the benefits and risks of pharmacological management?

Medications are only indicated for certain situations because they do carry some risks.

Below we outline the benefits and risks of the main delirium agents.

Haloperidol (Haldol)

While haloperidol is one of the oldest drugs used for delirium, it is still a first-line agent.

Compared with other antipsychotics, it is just as effective and safe and can decrease delirium symptoms. Haloperidol has a low risk of unwanted side effects such as low blood pressure and sedation.

It can be given by mouth or through injection into the muscle.

Doses can be started between 0.5 – 1 mg. Dose increase can occur by 2-5 mg every hour as needed until the total daily dose is reached. Doses can be increased up to 2 mg if needed.

Haloperidol does carry some safety concerns, particularly for the heart. These concerns can affect your heart rhythm, which can be dangerous.

Therefore, when taking haloperidol, providers should closely monitor an electrocardiogram (ECG).

An ECG evaluates heart function and health. Haloperidol also should not be used in Parkinson’s disease.

Atypical antipsychotics

Atypical antipsychotics include drugs such as quetiapine and olanzapine.

Data shows that these antipsychotics can be as effective in treating delirium.

Such drugs can also have a lower risk of certain side effects and can improve mental function.

While haloperidol is first-line for most situations, atypical antipsychotics are preferred in certain conditions such as Parkinson’s disease.

Other agents used to manage delirium in the elderly

Some studies have shown valproic acid’s effectiveness in treating delirium. It can be particularly useful in patients with mood disorders, traumatic brain injury, or alcohol withdrawal.

Other research exists suggesting that your body’s natural melatonin production is dysfunctional during delirium.

This suggests that melatonin may also reduce the likelihood of delirium in the elderly.

What medications should you avoid in delirium?

Benzodiazepines

Benzodiazepines, such as lorazepam, should be avoided in most situations.

This is because these medications can worsen mental function and cause sedation.

Such side effects can increase your risk for falls.

Benzodiazepines can be used, though, if alcoholism is suspected. If needed, benzodiazepines should be started at low doses for short periods of time.

Z-drugs (Sleep hypnotics)

Z-drugs, such as zolpidem (Ambien), should be avoided for similar reasons to benzodiazepines. They can cause dizziness, drowsiness, memory loss, and falls.

Anticholinergics

Anticholinergic medications should be avoided in the elderly due to anticholinergic side effects.

These effects include things such as drowsiness, dry mouth, constipation, falls, and more.

In people with dementia where cholinergic function is already severely compromised, giving anticholinergic medications can cause a precipitous decline in cognitive function.

The video below augments what I have written about delirium and its management:

What can caregivers do to help their loved ones who they suspect have delirium?

To reduce symptoms of delirium, caregivers can implement many of the preventative and non-pharmacologic treatment measures done in the hospital.

This includes maintaining a familiar environment, allowing visits from friends and family, and keeping a routine.

If a person becomes delirious, caregivers should also keep a close eye on them.

Delirium in the elderly can be dangerous and therefore it is important to closely monitor it and seek medical attention if needed.

Keep track of your loved one’s symptoms and medication list in case you do decide to seek medical attention.

This will help your provider make the appropriate clinical decision given your loved one’s medical history.

Back to our patient case…

To assess JD, her providers administer the CAM to screen JD for delirium.

Because her symptoms started suddenly and included inattention and disorganized thought, her doctor confirms she is CAM positive and experiencing delirium.

They begin to review JD’s medical and medication history. Her medication list includes:

JD’s Medication List

Drug	Dose and How Taken
Aspirin	81 mg by mouth daily (for heart)
Amitriptyline	100 mg by mouth at bedtime (for sleep)
Clonazepam	1 mg by mouth three times daily (For anxiety and sleep)
Digoxin	125 mcg by mouth daily (for heart)
Diphenhydramine	50 mg by mouth at bedtime (for sleep)
Levothyroxine	88 mcg by mouth 30 minutes before breakfast (for thyroid)
Losartan	20 mg by mouth daily (for blood pressure)
Omeprazole	20 mg by mouth daily (Stomach acid)
Trazodone	300 mg by mouth at bedtime (Sleep)

After reviewing JD’s medication list, it is clear that some of her medications are high-risk for delirium and could be contributing to her symptoms.

These include amitriptyline, clonazepam, diphenhydramine, and trazodone.

All these drugs can cause drowsiness or sedation, increasing JD’s risk for delirium.

Additionally, amitriptyline is an anticholinergic medication, which can cause confusion, delirium, and hallucinations, especially in older adults.

JD’s age, fall, and high-risk medications likely contributed to her delirious state.

Additionally, being in the hospital in an unfamiliar environment may also have caused disorientation.

JD’s doctors make the decision to discontinue these medications and implement proper sleep hygiene to improve her sleep.

Within a few days, JD’s symptoms resolve, and she returns to her normal cognitive functioning.

Although this case is rather simplified, it does address very commonly seen drug-related problems that many older adults and their caregivers are struggling with – hopefully, this post has helped shine some light on a medical issue that you need to be aware of, so that you can start and continue targeted conversations with your doctor.