Assessment and Management of Delirium in Older Adults in ...Article: AENJ-D-14-00040 Date: July 16,...

Article: AENJ-D-14-00040 Date: July 16, 2015 Time: 4:12

Advanced Emergency Nursing JournalVol. 37, No. 3, pp. 183–196

Copyright C© 2015 Wolters Kluwer Health, Inc. All rights reserved.

Assessment and Management ofDelirium in Older Adults in theEmergency DepartmentLiterature Review to Inform Development of aNovel Clinical Protocol

Tony Rosen, MD, MPH

Scott Connors, BS

Sunday Clark, MPH, ScD

Alexis Halpern, MD

Michael E. Stern, MD

Jennifer DeWald, RN

Mark S. Lachs, MD, MPH

Neal Flomenbaum, MD

AbstractDelirium occurs frequently in older patients in the emergency department (ED), is underrecognized,and has potentially serious consequences. Despite its seriousness, delirium is frequently missedby emergency providers, and patients with unrecognized delirium are often discharged from theED. Even when it is appropriately recognized, managing delirium in older adults poses a signifi-cant challenge for ED providers. Geriatric delirium is typically caused by the interaction of multiplefactors, including several that are commonly missed: pain, urinary retention, constipation, dehy-dration, and polypharmacy. Appropriate management includes nonpharmacological managementwith medication intervention reserved for emergencies. We have developed a new, comprehen-sive, evidence-based protocol for diagnosis/recognition, management, and disposition of geriatricdelirium patients in the ED with a focus on identifying and treating commonly missed contributingcauses. Key words: agitation, delirium, emergency medicine, geriatric

Author Affiliation: Division of Emergency Medicine(Drs Rosen, Clark, Halpern, Stern, and Flomenbaum,Mr Connors, and Ms DeWald) and Division ofGeriatrics and Palliative Medicine (Mr Connors andDr Lachs), Weill Cornell Medical College, New York.

The authors are grateful to the American Federationof Aging Research, which provided the funding forScott Connors’ participation through its Medical Stu-dent Training in Aging Research fellowship program.Dr Mark Lachs is the recipient of a mentoring awardin patient-oriented research from the National Instituteon Aging (K24 AG022399).Disclosure: The authors report no conflicts of interest.

DELIRIUM is frequently seen in olderpatients in the emergency depart-ment (ED), is underrecognized, and

has potentially serious consequences. Sevenpercent to 17% of older adults who present to

Corresponding Author: Tony Rosen, MD, MPH, Di-vision of Emergency Medicine, Box 179, Weill CornellMedical College, 525 East 68th St, New York, NY 10065([email protected]).

DOI: 10.1097/TME.0000000000000066

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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mailto:[email protected]


184 Advanced Emergency Nursing Journal

the emergency department (ED) suffer fromdelirium (Han, Wilson, & Ely, 2010). Deliriumis a medical emergency with significant asso-ciated morbidity and mortality requiring rapiddiagnosis and management (Han et al., 2010).Patients who have delirium in the ED have in-creased mortality, increased length of stay inthe hospital, and a higher risk of functional de-cline (Han, Shintani, et al., 2010; Han, Eden,et al., 2011). Patients with delirium diagnosedin the ED have a 12-month mortality rate of10%–26%, comparable with patients with sep-sis or acute myocardial infarction (Gower,Gatewood, & Kang, 2012).

Despite its seriousness, delirium is missedby ED physicians in 57%–83% of cases. (Hanet al., 2009, 2013). As many as 25% of patientswith unrecognized delirium are dischargedfrom the ED (Han et al., 2009, 2013). His-torically, patients discharged with undetecteddelirium are nearly three times more likelyto die within 3 months than those in whomdelirium is recognized in the ED (Kakumaet al., 2003). Delirious patients dischargedfrom the ED, particularly those with under-lying cognitive impairment, are less likelyto be able to accurately provide the reasonwhy they were in the ED or to understandtheir discharge instructions, creating signif-icant potential patient safety hazards (Han,Bryce, et al., 2011). The Society for AcademicEmergency Medicine Task Force has recom-mended delirium screening as a key qualityindicator for emergency geriatric care (Hanet al., 2009), and researchers have identifieddelirium as a crucial aspect of geriatric emer-gency medicine requiring additional research(Carpenter et al., 2011).

Managing delirious patients in the ED maypose a significant challenge, particularly ifthey become agitated. Patients may fall, pullout intravenous catheters or endotrachealtubes, not tolerate necessary invasive ther-apy, or even become violent, placing them-selves and their caregivers at risk for in-jury (Chevrolet & Jolliet, 2007). The healthcare team must intervene to ensure thesafety of the patient, staff, and other patientswhile evaluating for potential life-threatening

causes of acute mental status change. In ad-dition, the ED milieu itself can precipitateepisodes of delirium in older adults whoare not delirious when they initially present(Carpenter et al., 2011), particularly duringa lengthy ED stay. Effective management ofthese episodes may significantly improve pa-tient outcomes, whereas inappropriate orinadequate treatment can have disastrousconsequences.

The goal of our research was to thoroughlyreview the existing literature in order to de-velop a novel protocol to improve diagno-sis/recognition, management, and dispositionof geriatric patients with delirium in the ED.

MENTAL STATUS ASSESSMENTAND DELIRIUM DIAGNOSIS

Recognizing delirium among older adult EDpatients is challenging, but it is imperativefor effective management. Any patient whois not alert and oriented, who has behaviorchanges while in the ED, or whose appear-ance seems otherwise altered should be for-mally assessed for delirium. Because mentalstatus assessment depends on the patient’sbaseline mental status and the time courseof any changes, efforts should be made when-ever possible to acquire collateral informationfrom other informants such as family, friends,home health aides, and/or the skilled nursingfacility.

Several assessment tools have been devel-oped to assist nonpsychiatrists to diagnosedelirium (Han et al., 2010). The Confusion As-sessment Method (CAM) is the most widelyused instrument (Inouye et al., 1990; Wei,Fearing, Sternberg, & Inouye, 2008). The CAMevaluates four cognitive elements: (1) acuteonset and fluctuating course; (2) inattention;(3) disorganized thinking; and (4) altered levelof consciousness (Inouye et al., 1990). Tobe diagnosed with delirium, a patient mustdemonstrate Elements 1 and 2 as well as ei-ther 3 or 4 (Inouye et al., 1990). The CAMhas been extensively validated in several clin-ical settings (Inouye et al., 1990; Rolfson,McElhaney, Jhangri, & Rockwood, 1999; Wei



July–September 2015 � Vol. 37, No. 3 Delirium in Older Adults in the ED 185

et al., 2008). The CAM may be challenging touse routinely in a busy ED, however, becauseit requires as long as 10 min to perform (Hanet al., 2010). Researchers have recently eval-uated modified, shorter versions of this toolin the ED (Han et al., 2013; 2014): the Con-fusion Assessment Method for the IntensiveCare Unit and the brief Confusion AssessmentMethod (bCAM). Both were found to be veryspecific, with positive tests strongly sugges-tive of delirium, but with only modest sensitiv-ity (Han et al., 2013; 2014). A brief (less than20 s), more sensitive Delirium Triage Screenhas recently been proposed and evaluated asa preliminary step that may be used in con-junction with the bCAM to increase its sen-sitivity (Han et al., 2013). Research on theseand other tools is ongoing, but a definitive ap-proach for mental status assessment and delir-ium diagnosis in geriatric ED patients has notyet been identified.

CAUSES OF ACUTE DELIRIUM

Delirium is rarely caused by a single in-sult, but, similar to other syndromes in olderadults, including falls and failure to thrive,is typically due to the interaction of multi-ple contributing factors (Wilber, 2006). Re-searchers have described “predisposing fac-tors” that make the individual more vulner-able to delirium and “precipitating factors,”which are the insults that cause the acutemental disturbance (Inouye & Charpentier,1996). In the ED, it is important to identifypredisposing risk factors and to prevent orameliorate precipitating factors, because therisk of delirium increases with the numberof predisposing and precipitating risk factorspresent (Wilber, 2006). Therefore, a multi-component intervention is most likely to beeffective for delirium prevention or control(Inouye, 2006).

Management of delirium in the ED requirescareful assessment of potential precipitatingfactors. This includes a complete history andphysical examination, electrocardiographictests, blood and urine tests, chest radio-graphs, and consideration of further imaging.

Emergency department providers are veryfamiliar with, and experienced in, evaluatingfor immediately life-threatening deliriumtriggers such as infection, head trauma, elec-trolyte disturbance, myocardial infarction/acute coronary syndrome, hypoxia, hypo-glycemia, stroke, renal insufficiency, and liverfailure. Because there is a substantial bodyof literature regarding the identification andmanagement of these causes of delirium, theyare not discussed in detail here. This reviewof the literature focuses on the importanceof several more subtle precipitating factors,such as pain, urinary retention, constipation,dehydration, environmental distractions, andpolypharmacy, that may be more difficult torecognize and treat in the ED setting. Thesefactors are missed by ED providers becausethey may not be immediately life-threateningand ED providers are not trained to routinelycheck for them in patients with alteredmental status.

Pain

Uncontrolled pain is commonly identifiedas a significant delirium trigger (Schreier,2010). Patients admitted to the hospital fromlong-term care settings who received opioidmedications were more likely to experiencemild rather than moderate or severe delir-ium (Schreier, 2010). Among postoperativepatients, those who received less effectivepain management after hip fracture surgerywere more likely to suffer from delirium(Schreier, 2010). Although these studies arecorrelative rather than causative, they suggestthat complete pain assessment and adequatecontrol is relevant for prevention or manage-ment of delirium (Nassisi, Korc, Hahn, Bruns,& Jagoda, 2006). Unfortunately, ED physi-cians are less successful at treating pain inolder adults than in younger patients (Hwang,Morrison, Richardson, & Todd, 2011). This islikely partially due to reduced opiate prescrib-ing by ED practitioners because of concernsabout side effects, which include sedation anddelirium (Hwang et al., 2011). In cases wherea patient has severe pain, however, treatment




with opioids should be strongly considered(Nassisi et al., 2006) because this may pre-vent as well as manage delirium. Nonpharma-cological therapies to manage pain, includingice application, elevation, and immobilizationin the setting of acute injury may be con-sidered. In addition, local or regional drugtherapies that manage pain but have minimalsystemic effects, such as nerve blocks andepidural catheterization, may be consideredwhen appropriate (Hogan et al., 2006).

Urinary Retention

Significant urinary retention can precipitateor exacerbate delirium, a disorder referredto as cystocerebral syndrome (Waardenburg,2008). Urinary retention from prostatic hy-pertrophy, other mechanical blockage, or an-ticholinergic medications is common in el-derly ED patients and is underrecognized(Gower et al., 2012; Thorne & Geraci, 2009;Waardenburg, 2008). Research in geriatric re-habilitation patients has shown that 11%–21%of older adults who are asymptomatic retaina significant amount of urine (Borrie et al.,2001; Wu & Baguley, 2005). Bladder disten-sion may contribute to delirium due to the in-creased sympathetic tone and catecholaminesurge triggered by the tension on the bladderwall (Liem & Carter, 1991). Bladder scanningvia ultrasonography has been validated as anaccurate measure of retention (Borrie et al.,2001), and one study used a postvoid residualof 150 ml as a threshold for clinically signif-icant retention in a geriatric population (Wu& Baguley, 2005). Bladder decompression viastraight catheterization may improve symp-toms (Waardenburg, 2008). Whenever possi-ble, insertion of indwelling urinary cathetersshould be avoided in delirious older pa-tients (Young, Murthy, Westby, Akunne, &O’Mahony, 2010). Although frequently moreconvenient for care staff and sometimes re-quested by patients, these catheters limit pa-tient mobility, are a potential nidus of infec-tion, and have been shown to increase the riskfor delirium (Waardenburg, 2008). Therefore,intermittent catheterization is preferable for

urinary retention management (Hogan et al.,2006). Critically ill older adults, major traumavictims, and patients undergoing certain sur-gical procedures may require indwelling uri-nary catheters for a short term, but theseshould be removed as soon as clinically in-dicated (Fakih et al., 2010).

Constipation

Constipation is a frequent, often overlookedprecipitating factor for delirium (Morley,2007). Research suggests that 17%–40% ofadults older than 65 years may have chronicconstipation, with as many as 45% of frailolder adults suffering from it (Morley, 2007).Research in skilled nursing facilities findsthat 47% of residents have constipation and50% take daily laxatives (Tariq, 2007). No-tably, constipation is associated with verbaland physical aggression in nursing home pa-tients with dementia (Leonard, Tinetti, Allore,& Drickamer, 2006). Constipation may becaused by many factors, including immobil-ity, comorbid diseases such as diabetes melli-tus or colon cancer, electrolyte abnormalities,medications, and even depression (Morley,2007). A frequent cause of constipation is opi-oid pain medication. Although it is importantnot to withhold opioid analgesics, all patientsreceiving opiates should prophylactically begiven a stool softener unless a contraindica-tion exists (Ross & Alexander, 2001). A carefulhistory and physical examination, including arectal examination with consideration of dis-impaction, may also be helpful in assessingand managing delirious patients.

Dehydration

Dehydration is a common precipitating factorfor delirium, in part, because it leads to cere-bral hypoperfusion (Wilson & Morley, 2003).Dehydration in older adults is often relatedto acute illness and results in high mortal-ity (George & Rockwood, 2004). Dehydra-tion may have many causes, including de-creased thirst mechanism, physical limitationscausing inability to access water, swallowingdifficulty, cognitive impairment, and misuse




of diuretics (George & Rockwood, 2004).In addition, severe dehydration may indi-cate substandard care or neglect (George &Rockwood, 2004). Recognition of dehydra-tion in the ED can be challenging, as thephysical signs of dehydration, such as weightloss, decreased skin turgor, dry mucous mem-branes, tachycardia, and hypotension, whichare very useful in assessing younger adults,are unreliable in geriatric patients (George &Rockwood, 2004). As a result, a blood urea ni-trogen (BUN)/creatinine ratio of 18 or greaterhas been suggested by researchers as a thresh-old for identification and aggressive treatmentof dehydration in delirious elderly patients(Chu et al., 2011; Marcantonio et al., 2006).

Environmental Factors

Environmental factors also contribute to thedevelopment of delirium. The cacophonous,chaotic, unfamiliar, and potentially threaten-ing environment of the ED may be stress-ful and disorienting for geriatric patients(Carpenter et al., 2011). Because sensoryoverload has been shown to worsen delir-ium, providers should consider moving at-riskpatients out of the busy ED corridors intoquieter, more controlled settings (Dahlke &Phinney, 2008). In most EDs, however, pa-tients are less closely observed if removedfrom the hallway, so the potential bene-fits and risks must be weighed. An uncom-fortable temperature may also worsen delir-ium, so providers should consider adjust-ing the climate and adding/removing blan-kets as needed (Conley, 2011; Gillis & Mac-Donald, 2006). Immobility is another im-portant environmental risk factor for delir-ium (Rigney, 2006). Minimizing intravenouscatheters, wires, and monitors, which mayreduce mobility, is recommended (Rigney,2006). Frequent checks should be made to en-sure that patients have not become tetheredto devices or tangled in bedsheets or blankets.A soiled incontinence brief may also increasestress and disorientation for a delirious olderadult and increases risk of urinary tract infec-tion and superinfection of existing pressureulcers, potentially worsening delirium. There-

fore, every effort should be made to changeto a clean brief when appropriate.

Polypharmacy

Polypharmacy is very common among olderadults and frequently contributes to delirium(Wilber, 2006). Older patients presenting tothe ED take an average of 4.2 medications perday, with 91% taking at least one, 13% takingeight or more, and some taking as many as17 medications (Samaras, Chevalley, Samaras,& Gold, 2010). Of these patients, 31% havebeen prescribed a combination of medica-tions that may lead to at least one potentiallyadverse drug interaction (Hohl, Dankoff, Co-lacone, & Afilalo, 2001). The Beers criteriaalert clinicians about medications that, due topotentially dangerous side effects, are inap-propriate for older adults (Campanelli, 2012).Despite the existence of these criteria, Chinet al. (1999) found that 11% of elderly patientspresenting to the ED have been prescribed atleast one of the medications deemed inappro-priate by Beers and colleagues. Compoundingthis problem, Chin et al. (1999) also foundthat medications identified by the Beers list asinappropriate were given to 3.6% of elderlypatients in the ED and prescribed to 5.6%upon ED discharge. The medications mostfrequently linked to delirium among olderadults are those with anticholinergic prop-erties (Han et al., 2010). The types of med-ications commonly associated with deliriumamong older adults are described in Table 1.The effects of polypharmacy may be magni-fied during acute illness, with hepatic or renaldysfunction unexpectedly increasing the half-life and therefore the effect of medications. Acomplete medication history and careful con-sideration of medications and doses given inthe ED are essential parts of delirium manage-ment.

MANAGEMENT STRATEGIES

Practice guidelines emphasize that mostepisodes of delirium can be managed withnonpharmacological interventions and thatpharmacological treatment be limited to




Table 1. Medications most commonlyassociated with delirium

Medications with anticholinergic propertiesAntihistamines (such as diphenhydramine)Antispasmodics (such as oxybutynin)AntiemeticsAntiparkinsonian drugsAntipsychoticsa

Other psychoactive medicationsBenzodiazepinesAnticonvulsantsNarcotic pain medicationsb (particularly

meperidine)Nonpsychoactive medications

Digoxinβ -BlockersCorticosteroidsNonsteroidal anti-inflammatory agentsAntibiotics

Note. From Campanelli (2012), Han, Wilson, and Ely(2010), and Hogan et al. (2006).aAlthough antipsychotic medications are often used totreat delirium, these medications have anticholinergicproperties and may cause or worsen existing delirium.bAlthough very important for pain control and preven-tion of pain-induced delirium, narcotics may paradoxi-cally themselves contribute to delirium.

behavioral emergencies when a patient’s se-vere agitation is interfering with essential in-vestigations or treatment or placing him/heror others at risk (Hogan et al., 2006). Despitethis, there is currently no universally acceptedstrategy for managing a delirious patient inthe ED (Han et al., 2009). In fact, there issignificant variation in hospitalized inpatientmanagement of delirium, with many estab-lished treatments remaining underused andmost recommended management strategiesbased on common sense rather than empiricalevidence (Carnes et al., 2003; Pitkala, Laurila,Strandberg, & Tilvis, 2006).

Nonpharmacological Management

Nonpharmacological management recom-mendations include strategies for effectivecommunication with a delirious patient,which may be challenging, given these pa-

tients’ mental status fluctuations and difficultyin sustaining attention. Each time a nurseor physician interacts with a delirious olderadult, he/she should provide orienting infor-mation, reminding the patient where he/sheis, the date and time, and what is happeningto him/her (Aguirre, 2010). Addressing thepatient face-to-face, with instructions and ex-planations that are slow-paced, short, simple,and repeated, helps manage delirium (Hoganet al., 2006). Interpreters should be used ifthere is any concern that the patient mayhave difficulty understanding the language(Tropea, Slee, Brand, Gray, & Snell, 2008).Nurses and physicians should keep theirhands in sight whenever possible and avoidgestures or rapid movements or touching theolder person in an attempt to redirect him/herbecause these actions may trigger an episodeof agitation (Hogan et al., 2006).

Sensory impairment is a frequent contribu-tor to delirium, worsening disorientation andmaking communication difficult (Hogan et al.,2006). Many older adults have vision or hear-ing problems, and the eyeglasses and hear-ing aids they regularly use should be availableand worn when possible (Aguirre, 2010). Inaddition, the use of magnifying glasses andportable amplifying devices in the ED may behelpful for patients with severe sensory im-pairment (Aguirre, 2010).

Providers may request that family membersand friends, if available, stay with the olderperson (Aguirre, 2010). Family and friendscan assist with communication and reorien-tation (Hogan et al., 2006). Also, they maycalm, aid, protect, support, and advocate forthe patient (Hogan et al., 2006). Emergencydepartment providers may facilitate this byplacing the patient in a large enough room toaccommodate family members and bringingchairs to the bedside.

Environmental strategies may also be use-ful in managing delirium. Although frequentlychallenging in a crowded ED, reducing noisenear a patient may prevent the sensory over-load that can exacerbate delirium (Younget al., 2010). Large, easily visible clocks andcalendars may help reorient patients, as may




whiteboards displaying names of staff mem-bers and the day of the week (Aguirre, 2010).Low lighting to allow rest is ideal (Hoganet al., 2006; Young et al., 2010), but total dark-ness may prevent an older adult from perceiv-ing the environment correctly and reorient-ing him/herself if he/she awakens (Rigney,2006). In fact, use of nightlights has beenrecommended to reduce anxiety associatedwith waking up in unfamiliar surroundings(Rigney, 2006). The disorienting “timeless-ness” of an often windowless hospital en-vironment is confusing and interrupts olderadults’ sleep–wake cycles. Therefore, light-ing changes to cue night and day may behelpful.

Physical restraints should be avoided withagitated delirious older adults because theiruse may increase agitation and prolong delir-ium (Evans & Cotter, 2008). Notably, in onestudy, restraint use among patients in a medi-cal inpatient unit was associated with a three-fold increased odds of delirium persistenceat time of discharge (Inouye et al., 2007).In addition, physical restraints create addi-tional clinical problems, such as loss of mo-bility, pressure ulcers, and incontinence, andthey increase the chance of serious injury ordeath (Evans & Cotter, 2008). With antici-pated health care changes, including wors-ening ED overcrowding, budgetary cutbacks,nursing shortages, and decreased availabilityof one-to-one sitters, commentators are con-cerned about a potential resurgence of re-straint use (Inouye et al., 2007). Raising thehead and foot of the bed to prevent climb-ing or falling out may be a safer alternative(Somes, Donatelli, & Barrett, 2010).

The busy, crowded ED, where physiciansand nurses are frequently responsible for mul-tiple acutely sick patients, is a challenging en-vironment in which to employ these strate-gies. Nevertheless, it is important for EDproviders to consider using them wheneverpossible. Unfortunately, all studies to dateevaluating their use involve patients eitherin hospital wards or in rehabilitation facilitiesand not in EDs. Additional research is requiredto determine which nonpharmacological in-

terventions are feasible and cost-effective inthe ED (Han et al., 2010).

Pharmacological Management

In some circumstances, older adults’ severeagitation may require emergent medicationadministration to ensure their safety as wellas that of other patients and staff. Despitethe recommendation that medication be usedonly as a last resort, literature suggests thatmedication use is widespread, with the ma-jority of delirious hospitalized patients receiv-ing pharmacological intervention (Briskman,Dubinski, & Barak, 2010). Additional educa-tion regarding the efficacy of nonpharmaco-logical management techniques may be re-quired to change this practice.

After attempting nonpharmacological man-agement, care should be taken in select-ing pharmacological approaches to treatingdelirium. Although benzodiazepines are com-monly used to treat delirium in youngeradults, guidelines recommend that these med-ications be avoided as monotherapy unlesstreating delirium due to alcohol or benzodi-azepine withdrawal (Trzepacz et al., 1999).In older adults, benzodiazepines may precipi-tate or worsen delirium and can cause severeside effects, including oversedation, disinhi-bition, ataxia, and confusion (Pandharipandeet al., 2006).

International guidelines suggest thatproviders instead use antipsychotic medi-cations to treat behavioral emergencies ingeriatric delirium (Trzepacz et al., 1999).These medications include haloperidol, atypical antipsychotic, and newer, atypicalantipsychotics including olanzapine, queti-apine, and risperidone. Despite the routineuse of these antipsychotic medications fordelirious older adults in many EDs, thereis little reliable evidence supporting theirefficacy or safety (Devlin & Skrobik, 2011;Flaherty, Gonzales, & Dong, 2011). Largerstudies with rigorous methodology areneeded to accurately assess the efficacy ofthe different pharmacological approachesto treating geriatric delirium (Flaherty et al.,




2011; Ozbolt, Paniagua, & Kaiser, 2008). Aswith most medication interventions in olderadults, providers should always “start lowand go slow” because additional medicationmay always be given but it cannot be takenaway (Tobias, 2003). Unfortunately, researchsuggests that high doses are frequentlyadministered to delirious geriatric patientsand the medication orders are only rarelyreviewed (Tropea, Slee, Holmes, Gorelik, &Brand, 2009).

Disposition

Although little evidence-based guidance ex-ists for disposition of older ED patients withdelirium, most of these patients likely requirehospital admission. For patients who are ad-mitted, admission to a unit specializing inacute geriatric care may improve outcomes(Naughton et al., 2005).

NOVEL CLINICAL PROTOCOL

On the basis of this literature review, wehave developed a novel clinical protocol fordiagnosis/recognition, management, and dis-position of geriatric delirium in the ED (seeFigure 1).

Diagnosis/Recognition

Our protocol emphasizes the use of a formalmental status assessment tool for at-risk pa-tients. In addition, it asks providers to acquirecollateral information from family or a skillednursing facility whenever possible becausebaseline mental status and time course of be-havior change significantly affect assessment.Providers are also reminded that it is impor-tant to check vital signs immediately if anymental status change is suspected becauseof their implications for underlying causeand subsequent testing, management, anddisposition.

Management

Emergency providers are experienced andcomfortable with assessment and manage-

ment of immediately life-threatening con-ditions that may precipitate agitated delir-ium, such as sepsis, acute myocardial in-farction, or hypoglycemia. Our protocol re-minds providers to initially check for theseconditions.

The central focus of this protocol, how-ever, is on reminding the ED provider aboutthe importance of assessing for additionalcommonly missed contributing precipitantsof delirium in older adults as well as toprovide specific interventions to treat theseprecipitants. To assist providers with re-membering these contributing causes, wedeveloped a mnemonic, A-B-C-D-E-F (A =analgesia; B = bladder/urinary retention;C = constipation; D = dehydration; E =environment; F = f(ph)armacy/medications).For each of these potentially missed con-tributing causes, we have developed criticalaction(s) in evaluation and treatment. ForA = analgesia (poor pain control): Fullyexpose skin, palpate long bones and joints,consider if acute complaint is pain related,and check for a chronic pain condition.If pain is found: Intervene with adequateanalgesia. For B = bladder/urinary retention:Check the bladder via ultrasonography; ifmeasurement is greater than 150 ml: Emptythe bladder using a straight urinary catheter.For C = constipation: Perform a rectal ex-amination, consider disimpaction, and checkfor and potentially hold constipation-causingmedications. For D = dehydration: CheckBUN/creatinine ratio and, if it is 18 or greater,give a 500-ml bolus of isotonic intravenousfluid, if not contraindicated, and reassess. ForE = environment: Check if the patient is ina noisy hallway, is too hot or cold, is teth-ered to sheets/intravenous catheters/wires,or has a wet or soiled brief, and addresseach as appropriate. For F = f(ph)armacy:Perform a reconciliation for new, changed,or missing medications and avoid prescribingdelirium-causing medications.

In addition to the critical A-B-C-D-E-F evalu-ation of commonly missed factors that cancontribute to delirium, our protocol sug-gests other nonpharmacological actions that




Figure 1. Novel clinical protocol for emergency department management of delirium in older adults.ACS = acute coronary syndrome; BUN = blood urea nitrogen; CVA = cerebrovascular accident; EPS =extrapyramidal symptom; IM = intramuscular; IV, intravenous; MI = myocardial infarction; PO = bymouth; SL = sublingual.




providers may take to prevent or help treatdelirium.

Pharmacological Interventions

The protocol acknowledges that medicationadminstration to manage delirium-related be-haviors may be necessary to ensure thesafety of the patient and staff but encour-ages providers to use it only as a last re-sort. As well, the protocol emphasizes theavoidance of physical restraints. We recom-mend that providers first redose patients withtheir current psychotropic medications and,if possible, check their records for prior psy-chotropic use and adverse reactions.

Despite a literature review yielding lim-ited evidence, we have provided a chart ofvarious medication alternatives with recom-mended dosing and circumstances in whicheach medication may be beneficial or dele-terious choice (see Figure 2). Olanzapine,which is available in sublingual form in ad-dition to oral and intramuscular forms, is agood choice if a practitioner is concerned

about a patient’s ability to swallow a pill.Also, olanzapine is appropriate for individ-uals with a history of extrapyramidal symp-toms or evidence or concern for prolongedQT interval (Bhana, Foster, Olney, & Plosker,2001; Chung & Chua, 2011). Given this sideeffect profile, olanzapine is often an appro-priate first choice in the elderly ED patient.Olanzapine should be avoided in those at riskfor orthostatic hypotension (Escobar et al.,2008). Evidence suggests an increased riskof sudden death when intramuscular olanza-pine is used in combination with diazepam(Allen, Currier, Carpenter, Ross, & Docherty,2005).

Risperidone, although it is an unfamiliarmedication to many ED providers, it maybe a particularly good choice for patientswith underlying dementia complicating theiracute delirium (Alexopoulos, Streim, Carpen-ter, & Docherty, 2004). It is commonly usedin skilled nursing facilities to manage agitatedbehaviors. Of the atypical antipsychotics,risperidone has the highest likelihood for dan-gerous QT interval prolongation, so it should

Figure 2. Recommended medication interventions for emergency department management of deliriumin older adults. IM = intramuscular; IV, intravenous; PO = by mouth; SL = sublingual.




be avoided in at-risk patients (Chung & Chua,2011).

Quetiapine is an appropriate choice if seda-tion is desired (Devlin et al., 2010) and may beappropriate for patients with significant acutemedical illness who will require intensive careunit level care. Quetiapine should be avoidedin those with a known movement disorder(Rizos, Douzenis, Gournellis, Christodoulou,& Lykouras, 2009; Walsh & Lang, 2011); how-ever, it may prolong the QT interval at higherdoses, so providers should be wary of us-ing quetiapine in conjunction with other QT-prolonging drugs (Aghaienia, Brahm, Lussier,& Washington, 2011).

Haloperidol, commonly used in the emer-gent management of agitated younger pa-tients, is the medication that has been mostwell-studied for use in delirious older adults(Han et al., 2010). Haloperidol may be use-ful in situations where sedation is required(Attard, Ranjith, & Taylor, 2008) and, eventhough it is not Food and Drug Adminis-tration (FDA)-approved for intravenous use(FDA, 2013), it is commonly given intra-venously in emergent situations. Haloperidol,however, is potentially dangerous for manypatients because this medication is associatedwith an increased incidence of extrapyrami-dal symptoms, seizures, Parkinsonism, and aprolonged QT interval (Angelini, Ketzler, &Coursin, 2001). Many of these side effects maybe avoided with lower doses, so haloperidolshould likely be used for older adult ED pa-tients in much smaller doses than typicallygiven to younger patients.

Lorazepam and other benzodiazepines,which may cause paradoxical delirium, aretypically discouraged for use in deliriousolder adults, particularly for those at riskfor respiratory depression or hypotension(Pandharipande et al., 2006). In limited sit-uations, however, such as delirium due to al-cohol withdrawal and sedation for an ED pro-cedure or radiological test, lorazepam may bean appropriate choice (Gower et al., 2012;Trzepacz et al., 1999). As with the use ofmost medications in older adults, we empha-size “starting low and going slow.” If an ED

practitioner is unfamiliar with use of thesemedications, consultation with a geriatricianis also recommended.

Disposition

Safe disposition is imperative for older adultssuffering from delirium, and the ED is not anappropriate environment for these patients.Therefore, in our protocol, these patients areprioritized for transfer to inpatient units, par-ticularly units specializing in the care of geri-atric patients, where they can receive defini-tive care. Also, to ensure continuity of care,our protocol requires that both the ED nurseand the physician verbally report to the in-patient team that the patient is delirious andhow this condition has been managed as partof the transfer of care.

CONCLUSION

Assessing and managing agitated delirium inolder adults remains a significant challenge forED providers. We have synthesized existingliterature into an evidence-based, comprehen-sive A-B-C-D-E-F protocol that addresses manyof the factors precipitating delirium and pro-vided both nonpharmacological and pharma-cological approaches to manage them. Futureresearch involves implementing this protocoland measuring its efficacy.

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