Diagnosing and managing delirium in the elderly

OBJECTIVE To outline current approaches to diagnosing and managing delirium in the elderly. QUALITY OF EVIDENCE A literature review was based on a MEDLINE search (1966 to 1998). Selected articles were reviewed and used as the basis for discus sion of diagnosis and etiology. We planned to include all published randomi zed controlled trials regarding management but found only two. Consequently , we also used review articles and recent practice guidelines for delirium published by the American Psychiatric Association. MAIN FINDINGS Clinical diagnosis of delirium can be aided by using DSM-TV c riteria, the Delirium Symptom Interview, or the confusion assessment method . Management must include investigation and treatment of underlying causes and general supportive measures. Providing optimal levels of stimulation, r eorienting patients, education, and supporting families are important. Phar macologic management of delirium should be considered only for specific sym ptoms or behaviours, eg, aggression, severe agitation, or psychosis. Only o ne randomized controlled trial of tranquilizer use for delirium in medicall y ill people has been published. Findings support the current belief that n euroleptics are superior to benzodiazepines in most cases of delirium. Most authorities still consider haloperidol the neuroleptic of choice. Controll ed trials of the new atypical neuroleptics far treating delirium are not ye t available. Benzodiazepines with relatively short half-lives, such as lora zepam, are the drugs of choice for withdrawal symptoms. CONCLUSION Delirium is frequently underdiagnosed in clinical practice.:It s hould be suspected with acute changes in behaviour. Careful investigation o f the underlying cause permits appropriate management.