DELIRIUM IN THE ELDERLY - OPTIMAL MANAGEMENT

Delirium is common, morbid and costly, especially among hospitalised e lderly patients. Nonetheless, it remains under-recognised and often po orly managed. This article summarises the 5 key steps in the optimal m anagement of delirium. The first step is to precisely define the syndr ome of delirium, using key features described in the Diagnostic and St atistical Manual of Mental Disorders (fourth edition) [DSM-IV] or the Confusion Assessment Method. Key features include an acute onset of me ntal status change, fluctuating course, the presence of inattention, a nd either disorganised thinking or an altered level of consciousness. The second step involves the identification of patients at high risk o f delirium before it develops, so that preventive measures can be impl emented. Risk factors for delirium include advanced age, dementia, imp aired functional status, chronic comorbidities and medications, and th e severity of the acute illness or surgery. The third step is improved recognition of delirium. Very often, the presence of delirium is neit her diagnosed nor properly documented in the medical record. The fourt h step is to appropriately evaluate the delirious patient to assess al l important contributors to the syndrome. This evaluation will usually involve a careful history, medication review, physical examination an d selected laboratory testing. The fifth, and most important, step is the management of the delirious patient. The key elements of managemen t are treating the primary condition(s) leading to delirium, removing all treatable contributing factors, maintaining behavioural control, a nd supporting the patient and their family.