Delirium in older adults — assessment and management (MEQ)

(i) Definition and CAM. Delirium is an acute, fluctuating disturbance of attention and awareness with additional cognitive change due to a medical, toxic, or withdrawal cause (DSM-5-TR/ICD-11 framing). CAM is positive when acute onset and fluctuating course AND inattention are present, plus either disorganised thinking or altered level of consciousness. Attention must be tested; collateral confirms change from baseline. This case is delirium superimposed on dementia until proven otherwise.[1][3][4]

(ii) Hypoactive risk and factors. Hypoactive delirium presents as quiet lethargy and poor intake; staff may mislabel it as "settled" or depression. It is frequently missed and associated with worse outcomes. Predisposing here: advanced age, Alzheimer disease (DSD risk), polypharmacy. Precipitating: pneumonia (infection/hypoxia), hospital environment/sleep disruption, anticholinergic oxybutynin, benzodiazepine temazepam. Multifactorial vulnerability × load model applies.[3][4][7]

(iii) Non-drug care. Multicomponent HELP-style package: reorientation (clocks, calendars, name board), family presence, day-night lighting and sleep hygiene, early mobilisation, glasses/hearing aids, hydration and nutrition, treat constipation/retention, minimise unnecessary catheters and restraints, and stop or minimise deliriogenic drugs. Treat pneumonia fully in parallel. These measures prevent and treat; they are first-line, not optional add-ons.[2][8][3]

(iv) Benzodiazepines and antipsychotics. Avoid benzodiazepines for non-withdrawal delirium — they worsen confusion and falls; deprescribe temazepam if safe. Antipsychotics do not treat the syndrome (MIND-USA and related evidence against routine use). Reserve low-dose short-term antipsychotic only if severe distress or imminent danger after non-drug measures — e.g. haloperidol 0.25–0.5 mg PO/IM, olanzapine 2.5–5 mg, or quetiapine 12.5–25 mg, with ECG/QTc and EPS monitoring, daily review, and clear target of safety/distress rather than "cure confusion."[4][5]

(v) Capacity, risk, disposition. Capacity is decision-specific and often impaired while delirious; document understanding, retention, weighing, communication for each decision; reassess when lucid; use least-restrictive local legal framework and substitute decision-makers as required. Risk: falls, aspiration, wandering, vulnerability. Disposition: complete medical treatment, falls prevention, deprescribing plan, carer education that cognition may lag recovery, cognitive follow-up, and do not discharge alone while still delirious without a safety net. Delirium associates with mortality, institutionalisation, and later dementia risk.[3][6]