How do hospitals treat delirium in the elderly? A comprehensive guide for families and caregivers

Delirium occurs in up to 50% of hospitalized older adults and is associated with significant health risks. Therefore, understanding how do hospitals treat delirium in the elderly? is vital for families seeking to ensure their loved one receives the most effective and compassionate care during an episode of acute confusion.

Quick Summary

Hospitals manage delirium in older patients by first identifying and treating the underlying cause, which can range from infections to medication side effects. The care plan then incorporates supportive, non-pharmacological measures, such as environmental adjustments and reorientation, often supplemented with medication for severe agitation.

Key Points

• Root Cause Investigation: The primary step in hospital treatment is an exhaustive medical evaluation to identify the underlying trigger of the delirium, such as infection or medication side effects.

• Non-Pharmacological Approach: Supportive care, including environmental adjustments, reorientation, and family involvement, is the most crucial part of treatment, prioritizing a calm and familiar setting.

• Limited Medication Use: Pharmacological intervention is used sparingly for severe agitation or psychotic symptoms, and only when non-drug methods fail, to ensure patient safety.

• Team-Based Care: An interdisciplinary team of physicians, nurses, and therapists collaborates to manage all aspects of the patient's physical and cognitive needs.

• Prevention is Key: Hospitals implement preventive measures like the Hospital Elder Life Program (HELP) to minimize the risk of delirium, especially in vulnerable seniors.

• Sensory Support: Providing a patient with their glasses, hearing aids, and other sensory devices is a simple but critical step to improve orientation and reduce confusion.

• Avoid Restraints: Physical and chemical restraints are avoided whenever possible to prevent increased agitation, further confusion, and complications.

The First Step: Identifying the Underlying Cause

Successful treatment of delirium is highly dependent on accurately and promptly identifying the precipitating factor. Since delirium is not a disease itself but a syndrome with various triggers, hospitals employ a methodical approach to pinpoint the cause.

Comprehensive Medical Evaluation

Upon recognizing the signs of delirium, the care team conducts a thorough medical workup. This begins with a detailed history, including a review of all medications, both prescription and over-the-counter, that the patient was taking before admission. Medications, especially anticholinergics, opioids, and sedatives, are a frequent cause of delirium and are often discontinued or adjusted.

1. Medication Review: A pharmacist or physician scrutinizes the patient's drug regimen for new medications, recent dose changes, or the discontinuation of chronic medications like alcohol or benzodiazepines.
2. Infection Screening: Common infections, such as urinary tract infections (UTIs) or pneumonia, can trigger delirium. The hospital performs tests like blood and urine cultures, urinalysis, and chest X-rays to check for infection.
3. Metabolic and Electrolyte Analysis: Blood tests are ordered to check for imbalances in electrolytes (sodium, calcium), kidney and liver function, blood sugar levels, and thyroid function, which are all potential causes.
4. Addressing Pain: Untreated or inadequately managed pain is a major precipitant of delirium. The care team assesses and manages the patient's pain using non-opioid medications and other strategies where possible.

The Foundation of Care: Non-Pharmacological Interventions

Non-pharmacological strategies are the cornerstone of delirium management and are prioritized over medication. These interventions focus on supporting the patient's brain function and creating a safe, therapeutic environment.

Environmental and Supportive Measures

These steps aim to reduce sensory overload, provide cognitive stimulation, and maintain a consistent routine.

• Optimizing the Environment: The patient's room is kept quiet and calm, especially at night, with minimal distractions. Natural light is used during the day to help regulate the sleep-wake cycle, and a clock and calendar are placed in clear view.
• Reorientation Techniques: Staff and family members should frequently reorient the patient by calmly stating the time, date, place, and reason for their hospital stay. Simple, clear communication is essential, avoiding arguments or excessive questioning.
• Sensory Aids: Ensuring the patient has their eyeglasses, hearing aids, and dentures readily available and in use helps reduce confusion and improve their connection to the environment.
• Early Mobilization: The care team encourages and assists the patient to get out of bed and engage in light physical activity, which can significantly shorten the duration of delirium.
• Family Involvement: Familiar faces are incredibly reassuring. Hospitals encourage family and friends to visit and participate in the patient's care, offering comfort and familiarity.

Medication's Role: A Cautious and Targeted Approach

Medication is not used to cure delirium but to manage severe, unmanageable symptoms that pose a threat to the patient's or staff's safety. The use of psychotropic medication is approached with extreme caution, particularly in older adults.

When Medications Are Necessary

If non-pharmacological methods fail to control severe agitation, fear, or hallucinations, a physician may prescribe a low-dose antipsychotic for a short period.

• Antipsychotics: Medications like haloperidol or atypical antipsychotics (e.g., risperidone, quetiapine) may be used. The lowest effective dose is given for the shortest possible duration, as these medications carry risks for older adults.
• Benzodiazepine Avoidance: In most cases, benzodiazepines are avoided as they can worsen delirium. They are only appropriate for treating delirium caused by alcohol or sedative withdrawal.

The Multidisciplinary Team Effort

Effectively treating delirium requires the collaboration of many healthcare professionals. The coordinated effort ensures all aspects of the patient's well-being are addressed.

Team Member	Role in Delirium Care
Hospitalist/Physician	Diagnoses delirium, determines and treats the underlying medical cause, and manages overall medical care.
Nursing Staff	Provides continuous bedside care, implements non-pharmacological strategies, monitors symptoms, and reassures the patient.
Pharmacist	Reviews all medications to identify and mitigate drugs that may cause or worsen delirium.
Physical/Occupational Therapists	Promotes early mobilization and helps maintain the patient's daily routine and cognitive function.
Social Worker	Supports the family and patient, assisting with long-term care planning and addressing psychosocial needs.
Family/Caregivers	Offers comfort, provides familiarity, and assists with reorientation and symptom monitoring.

Preventing Delirium in At-Risk Seniors

Prevention is the most effective approach to managing delirium. Hospitals implement proactive strategies to reduce the risk in vulnerable patients.

The Hospital Elder Life Program (HELP)

Many hospitals adopt multicomponent intervention programs like HELP, which target key risk factors for delirium, including sleep deprivation, immobility, sensory impairment, and dehydration. This preventative approach has been shown to reduce the incidence and duration of delirium significantly.

Key components include:

• Daily cognitive engagement activities.
• Protocols for uninterrupted sleep at night.
• Assistance with vision and hearing aids.
• Early and consistent mobilization.
• Management of hydration and nutrition.
• For more information on these strategies, visit Health in Aging for caregiver resources.

Conclusion

Hospitals treat delirium in the elderly through a methodical and multidisciplinary approach centered on finding and resolving the underlying cause. While medication can play a limited role in managing severe symptoms, the primary focus is on non-pharmacological interventions that create a safe, supportive, and orienting environment for the patient. By combining expert medical care with compassionate, coordinated supportive strategies, hospitals can help older adults recover from this challenging condition and minimize long-term health consequences.

Frequently Asked Questions

How long does it take for delirium to resolve in the elderly?

The duration of delirium can vary significantly among older adults. In many cases, it resolves within a few days once the underlying cause is addressed. However, it can sometimes persist for weeks or months, and some patients may experience a slower, incomplete recovery, especially if they have pre-existing cognitive issues like dementia.

What is the difference between delirium and dementia?

Delirium is an acute, sudden change in mental status that fluctuates throughout the day, while dementia is a chronic, progressive decline in cognitive function over a longer period. Delirium has a clear, often reversible cause, whereas dementia does not. It is also possible for someone with dementia to experience an episode of delirium.

Can family members visit during a delirium episode?

Yes, in many cases, family presence is encouraged and highly beneficial. Familiar faces can provide comfort, reassurance, and assist with reorientation. Family members should communicate with staff to ensure their presence is managed in a way that is most helpful for the patient.

What are common triggers for delirium in older adults in a hospital?

Common triggers include infections (like UTIs), medication side effects (opioids, sedatives), recent surgery, dehydration, electrolyte imbalances, severe pain, sleep deprivation, and environmental changes. Older adults with pre-existing conditions like dementia are particularly vulnerable.

Why are physical restraints not recommended for delirious patients?

Physical restraints can increase agitation, fear, and confusion in a delirious patient. They can also lead to complications like injury, pressure ulcers, and deconditioning. Most hospitals prioritize de-escalation techniques and constant observation over physical restraint.

Is it safe to give sedatives to an elderly patient with delirium?

Benzodiazepine sedatives are generally avoided as they can worsen confusion and symptoms. Low-dose antipsychotics may be used in specific, severe cases of agitation that don't respond to non-drug methods, but only with careful consideration due to potential side effects.

What happens after the patient is discharged from the hospital?

Recovery can continue for weeks or months. Follow-up care is crucial, focusing on monitoring cognitive status, managing underlying health conditions, and ensuring a smooth transition back home or to a rehabilitation facility. A patient's memory of the episode may be impaired or frightening, so family and caregiver support is essential.