Delirium, Dementia, and Amnesia in Emergency Medicine Treatment & Management

Updated: Apr 07, 2017
  • Author: Paul S Gerstein, MD; Chief Editor: Gil Z Shlamovitz, MD, FACEP  more...
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Treatment

Prehospital Care

Prehospital care workers involved in the transport of an acutely confused, combative, or delirious patient must ensure the safety of the patient and staff.

Prior to transport, consider sedation with a benzodiazepine with or without an antipsychotic if unable to easily control an agitated patient without physical restraints. Keep in mind that excess sedation may obscure the Mini-Mental Status Examination (MMSE) in the ED.

Use the least restrictive physical restraints if necessary for safe transport.

Provide supplemental oxygen.

Intubate when the airway is at risk or when the patient is comatose or has a poor gag reflex. Protect the cervical spine in the setting of trauma.

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Emergency Department Care

ED physicians caring for the patient with agitation, confusion, delirium, combativeness, or obtundation must ensure the safety of both the patient and the staff while attending to issues of airway protection and immediate recognition and treatment of rapidly reversible problems (eg, hypoxia, hypoglycemia, narcotic overdose).

Provide supplemental oxygen unless oxygen saturation is above 93% on room air.

When carbon monoxide poisoning is suspected, ignore the oxygen saturation, obtain a carboxyhemoglobin level, and provide 100% oxygen.

In cases of airway compromise, coma, or poor gag reflex, the ED physician should have a low threshold for intubation. Use rapid sequence intubation (RSI), particularly in the settings of possible head trauma, elevated ICP, or a combative patient. RSI/intubation may be necessary to facilitate imaging studies.

Treat suspected overdose-induced delirium based on ingestion history and/or toxidromes. Such treatment may range from simple observation and supportive care, activated charcoal, lavage (rarely performed), sedation, specific antidotes to intubation/life support.

Behavioral control of a patient with delirium who is agitated and combative should be primarily medication-based with physical restraining kept at a minimum and for protection of both the patient and staff (see Medication).

Conversely, inpatient and ICU prevention and management of delirium should strive to avoid or minimize use of sedating medications. These medications increase confusion, reduce attentiveness, impair orientation and thereby cause or exacerbate delirium. A prospective study of ICU patients, for example, found that lorazepam sedation increased the risk of delirium by 20%. [11] Most cases of delirium are helped by reassuring, compassionate human contact—particularly by those with whom the patient is familiar.

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Consultations

Specific cases may require consultation with neurosurgery, neurology, or internal medicine subspecialists (eg, infectious disease, endocrinology, nephrology, gastroenterology, toxicology, psychiatry).

In the setting of trauma or neurosurgical emergency, notify surgeons early in the workup. When available, a neurosurgeon should be consulted before using mannitol or high-dose steroid therapy.

The patient's private physician and/or family members are often the best sources of information regarding baseline functioning, prior medical history, and current medications.

Consult social services for home evaluation and placement issues for patients with dementia.

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