Psych · Old age psychiatry — delirium and acute cognitive syndromes
Delirium in older adults
Also known as Geriatric delirium · Acute confusional state in the elderly · Delirium superimposed on dementia · Postoperative delirium in older adults · Hypoactive delirium · Hospital delirium elderly
Exam-exhaustive fellowship reference on delirium in older adults — CAM/3D-CAM/4AT algorithms, hypoactive miss, multifactorial vulnerability model, HELP multicomponent prevention, treat precipitants first, avoid benzodiazepines except withdrawal, cautious low-dose short-term antipsychotics only for severe distress or danger with MIND-USA/AID-ICU/Agar evidence, DSD, capacity, and disposition. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- New fluctuating confusion with inattention in an older adult — medical emergency until causes treated; do not rebadge as primary psychosis or 'just dementia'
- Hypoactive delirium (quiet, lethargic, poor intake) — frequently missed and associated with worse outcomes
- Treating non-withdrawal delirium with benzodiazepines — often worsens confusion and falls risk
- Routine or high-dose antipsychotics without non-drug measures or cause treatment — not disease-modifying and potentially harmful
- Alcohol or benzodiazepine withdrawal — needs benzodiazepines and thiamine, not antipsychotic monotherapy
- Assuming decision-making capacity is intact for discharge, consent, or self-discharge while delirious
- Wernicke risk (poor nutrition, alcohol) — give parenteral thiamine before prolonged glucose loads
Meet the patient
An 87-year-old woman with moderate Alzheimer disease arrives from her nursing home at 4pm. The transfer letter says: "Increasing confusion over four days — please assess for progression of dementia." There are no observations on it.[3][4]
She is drowsy but rousable, has not passed urine since this morning, and cannot get past October on months-of-the-year backwards. Her daughter says she did the crossword last Sunday.[1][13]
Two exam questions are live. Which single word in that transfer letter is wrong? And what will you ask the facility for before you even see her? Everything below answers both.[3][4][12]
References18ShowHide
- [1]Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium Ann Intern Med, 1990.PMID 2240918
- [2]Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients N Engl J Med, 1999.PMID 10053175
- [3]Marcantonio ER Delirium in Hospitalized Older Adults N Engl J Med, 2017.PMID 29020579
- [4]Oh ES, Fong TG, Hshieh TT, et al. Delirium in Older Persons: Advances in Diagnosis and Treatment JAMA, 2017.PMID 28973626
- [5]Wilson JE, Mart MF, Cunningham C, et al. Delirium Nat Rev Dis Primers, 2020.PMID 33184265
- [6]Girard TD, Exline MC, Carson SS, et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness N Engl J Med, 2018.PMID 30346242
- [7]Andersen-Ranberg NC, Poulsen LM, Perner A, et al. Haloperidol for the Treatment of Delirium in ICU Patients N Engl J Med, 2022.PMID 36286254
- [8]Agar MR, Lawlor PG, Quinn S, et al. Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized Clinical Trial JAMA Intern Med, 2017.PMID 27918778
- [9]Burry L, Mehta S, Perreault MM, et al. Antipsychotics for treatment of delirium in hospitalised non-ICU patients Cochrane Database Syst Rev, 2018.PMID 29920656
- [10]Neufeld KJ, Yue J, Robinson TN, et al. Antipsychotic Medication for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta-Analysis J Am Geriatr Soc, 2016.PMID 27004732
- [11]Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness N Engl J Med, 2013.PMID 24088092
- [12]Witlox J, Eurelings LS, de Jonghe JF, et al. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis JAMA, 2010.PMID 20664045
- [13]Bellelli G, Morandi A, Davis DH, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people Age Ageing, 2014.PMID 24590568
- [14]Marcantonio ER, Ngo LH, O'Connor M, et al. 3D-CAM: derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium: a cross-sectional diagnostic test study Ann Intern Med, 2014.PMID 25329203
- [15]Meagher DJ, Leonard M, Donnelly S, et al. A longitudinal study of motor subtypes in delirium: frequency and stability during episodes J Psychosom Res, 2012.PMID 22325705
- [16]Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis JAMA Intern Med, 2015.PMID 25643002
- [17]Hshieh TT, Yang T, Gartaganis SL, et al. Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness Am J Geriatr Psychiatry, 2018.PMID 30076080
- [18]Inouye SK, Charpentier PA Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability JAMA, 1996.PMID 8596223