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

Updated: Sep 19, 2018
  • Author: Richard D Shin, 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, 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.

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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.

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Prevention

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]

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