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Delirium in Older PersonsAdvances in Diagnosis and Treatment

Educational Objective
To review the clinical management of patients with delirium.
1 Credit CME
Key Points

Question  What advances in diagnosis, prevention, and management of delirium in older adults have been introduced in the last 6 years?

Findings  Brief screening tools and improved delirium severity measurement tools have been developed for recognition and risk stratification of delirium. Delirium prevention with nonpharmacologic multicomponent strategies is effective. For pharmacologic management of delirium, the benefits do not outweigh the harms, and recommendations are to reserve treatment for patients with severe agitation that poses safety risks.

Meaning  Advances in screening and diagnosis of delirium can improve recognition and risk stratification, while implementation of nonpharmacologic delirium prevention strategies can substantially improve outcomes among older patients.


Importance  Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has serious adverse effects on the individual’s function and quality of life, as well as broad societal effects with substantial health care costs.

Objective  To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field.

Evidence Review  Search of Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011, until March 16, 2017, using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non–English-language articles were excluded.

Findings  Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment; 4 A’s Test; and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method–Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of delirium, based on recent reviews of the evidence, recommend reserving use of antipsychotics and other sedating medications for treatment of severe agitation that poses risk to patient or staff safety or threatens interruption of essential medical therapies.

Conclusions and Relevance  Advances in diagnosis can improve recognition and risk stratification of delirium. Prevention of delirium using nonpharmacologic approaches is documented to be effective, while pharmacologic prevention and treatment of delirium remains controversial.

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Article Information

Corresponding Author: Esther S. Oh, MD, PhD, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, 5200 Eastern Ave, Seventh Floor, Baltimore, MD 21224 (eoh9@jhmi.edu).

Accepted for Publication: August 9, 2017.

Author Contributions: Drs Oh and Inouye had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Hshieh.

Obtained funding: Inouye.

Administrative, technical, or material support: Oh, Hshieh, Inouye.

Supervision: Oh, Inouye.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This work was supported in part by grant K23AG043504 from the National Institutes of Health/National Institute on Aging (NIA) (Dr Oh); the Roberts Fund (Dr Oh); grant 3UL1TR001102 from the National Center for Advancing Translational Sciences (Dr Fong); grants P01AG031720 (Dr Inouye), R24AG054259 (Dr Inouye), R01AG044518 (Dr Inouye), and K07AG041835 (Dr Inouye) from the NIA; and by the Milton and Shirley F. Levy Family Chair (Dr Inouye).

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We gratefully acknowledge the assistance of Asha Albuquerque, BA, and Alexandra Pletnikova, BA, for the literature review in this study and the assistance of Eyal Kimchi, MD, PhD (Department of Neurology, Massachusetts General Hospital, Harvard Medical School), for his critical review of an earlier draft of this manuscript. We are also grateful to Carrie Price, MLS (William H. Welch Medical Library, the Johns Hopkins University School of Medicine), for her assistance with the literature search. These persons received no extra compensation for their contributions. This work is dedicated to the memory of Joshua Bryan Inouye Helfand and Lynne Morishita.

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