Approach Considerations
All patients with unresolved delirium require admission and often require telemetry or ICU care.
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.
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, gastrointestinal lavage (rarely performed), sedation, specific antidotes to intoxication and life support.
The treatment of delirium is dependent on the identification of the underlying cause, which may not be elucidated during an ED stay. If patients remain delirious they should be admitted for further observation.
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%. [17] Most cases of delirium are helped by reassuring, compassionate human contact—particularly by those with whom the patient is familiar.
Consultations
Specific cases may require consultation with neurosurgery, neurology, or medicine subspecialists (eg, infectious disease, endocrinology, nephrology, gastroenterology, toxicology, psychiatry).
In the setting of trauma or neurosurgical emergency, notify surgeons early in the workup for surgical emergencies that are contributing to the patient's delirium.
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.
Medical Care
Outpatient medications for primary dementia are coordinated best by healthcare providers who have continuing contact with the patient. Medications may include the following:
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Anticholinesterase inhibitors, such as donepezil (Aricept), galantamine (Razadyne), and rivastigmine (Exelon): These medications are useful early in the disease course, but they lose their effectiveness or may worsen mental status in advanced stages of the disease.
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N -methyl D -aspartate (NMDA) receptor antagonists, including memantine (Namenda)
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Antidepressants, especially the selective serotonin reuptake inhibitors or bupropion. Avoid tricyclic antidepressants because of their anticholinergic properties which can worsen dementia.
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Benzodiazepines for sedation or sleep. However, these drugs may worsen cognitive deficits, increase the risk of falls and are best avoided if possible.
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Antipsychotics for psychotic ideation or aggressive behavior: High-potency agents are preferred. Risperidone (Risperdal), a newer atypical antipsychotic, is well tolerated and useful for sundowning. However, the atypical antipsychotics as a group have been associated with a slightly higher death rate in patients with dementia (3.5% vs. 2.3% for placebo). Despite a US Food and Drug Administration (FDA) black box warning, experts warn against abandoning this class of medications in the treatment of dementia-related psychosis and aggression.
Prevention
Delirium
To date, few clinical studies have been published on preventing delirium; nevertheless, they have already indicated that around 30% to 40% of delirium episodes are preventable. Immobility, using physical constraints, using bowl catheter, malnutrition, psychadelics, some types of drugs, associated diseases, and dehydration in the individual can cause delirium symptoms. Old age, severe illness, dementia, physical frailty, infection and/or dehydration, vision impairments, drug interference caused by polypharmacy, surgery, and excessive use of alcohol are among other risk factors for delirium.
Yale Clinical Trial was the first controlled clinical trial that showed there are other non-pharmacological ways to prevent delirium in geriatric patients. This intervention included employing a standardized protocol on taking medical measures to eliminate or reduce the 6 risk factors of delirium in individuals older than 70 years. The 6 delirium risk factors in this study were cognitive impairment, sleep deprivation, immobility, visual impairments, hearing impairment and dehydration. The results of this study showed that delirium symptoms were 9.9% in intervention group in comparison with 15% in the usual-care group. The total number of delirium and the total number of its episodes showed a significant decrease in the intervention group. This intervention was associated with considerable improvement in the degree of cognitive impairment manifested in patients with cognitive impairment at admission as well as significant reduction in the rate of use of sleep medications in all patients in the intervention group. [18]
Dementia
Various substances to prevent or retard the onset of dementia have been proposed and/or studied. Prevention mechanisms have included preservation of CNS supporting cells, prevention of CNS inflammation, or free-radical inhibition. Unfortunately, no supplement or medication has been conclusively shown to prevent or retard the progression of dementia.
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Vitamin E: The suggested dose for prevention is 200-400 IU/d; much higher doses are sometimes given for treatment. The mechanism of action may be antioxidant, free-radical inhibition. Efficacy is controversial and vitamin E can increase mortality risk. Therefore, should only be considered for patients with AD or at high risk for AD.
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Vitamin B-6, vitamin B-12, and folate: These reduce levels of homocysteine, a potential brain neurotoxin. Efficacy is controversial and recent studies show no benefit.
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Statin cholesterol-lowering medications: Reports suggest that these drugs substantially protect against dementia via an effect not related directly to blood levels of cholesterol. Mechanisms of action may be reduction of insulin levels in the brain and/or C-reactive protein (CRP) levels in the blood (indicative of inflammation). A study of more than 17,000 adults older than 60 years in Finland concluded that statins appeared to reduce risk by 58%. [22] Other studies have found no benefit to statins in delaying dementia progression in patients with AD.
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Estrogen replacement: This is being studied, but no evidence of benefit has been found at present.
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Ginko biloba: This is a medicinal herb considered safe but of questionable efficacy. Preparations are of uncertain purity and dose consistency.
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High caloric intake in concert with obesity and sedentariness is associated with an increased risk of Alzheimer disease.
Undertreated depression, hypertension, diabetes mellitus, hypercholesterolemia and obesity have all been associated with higher risk of Alzheimer disease.
Excessive amounts of alcohol act as a neurotoxin and can increase Alzheimer disease risk. In moderate doses, alcohol inhibits cerebrovascular disease although it may still enhance brain atrophy. However, recent studies suggest that moderate drinking is protective against dementia as compared with abstinence. Antioxidants in wine (bioflavonoids) may be additionally beneficial (over spirits and beer).
Sedentary lifestyle is an independent risk factor for dementia. Regular exercise is protective.
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Coronal T1-weighted MRI scan in a patient with moderate Alzheimer disease. Brain image reveals hippocampal atrophy, especially on the right side.
