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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #29, #41, #42, #43, #55, #57, #58

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LEARNING OBJECTIVES

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Learning Objectives

  • Learn the epidemiology, pathophysiology, clinical presentations, evaluation, and management of delirium in older adults.

  • Understand the role of various predisposing and precipitating factors in increasing risk of older persons to delirium and associated prognosis and mortality.

  • Recognize the significance and limitations of routine as well as special laboratory and imaging tests commonly used to evaluate an older patient with delirium.

  • Learn the special relationship between dementia and delirium and the role of certain medications in predisposing older adults to delirium.

  • Gain a clear understanding of the specific indications and efficacy of various treatments, including pharmacologic and nonpharmacologic strategies commonly used to manage delirium.

  • Understand the latest concepts about special issues related to delirium, including patient preferences and decision making, delirium in nursing homes, and palliative and end-of-life care.

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Key Clinical Points

  1. Delirium is commonly encountered in older adults in various clinical settings and associated with significant morbidity and mortality, especially in intensive care units, inpatient settings, nursing homes, and following major medical illnesses or surgery.

  2. Delirium is commonly unrecognized in up to 70% of older patients and can lead to long-term functional and cognitive deficits.

  3. The pathophysiology of delirium is currently unclear, but posited to be the end result of multiple pathogenic pathways eventually culminating in the dysfunction of various neurotransmitters and major brain networks.

  4. Delirium is commonly due to multiple causes and the most effective treatment strategy is to identify and address as many predisposing and precipitating factors as possible.

  5. Among the precipitating factors, decreased mobility is strongly associated with delirium and medical equipment and devices may further contribute to immobilization.

  6. Dementia is the underlying risk factor in almost 75% of cases of delirium, and must be suspected in patients with slowly progressive cognitive and functional deficits.

  7. Acute onset, varying levels of alertness, and inattention are cardinal features of delirium, and obtaining historical details from a close family member or friend is critical in making a correct diagnosis of delirium.

  8. Lethargy and reduced psychomotor functioning are common presentations of delirium in older patients, in contrast to the hyperactive form more common in younger patients.

  9. Nonpharmacologic strategies are the preferred treatment for delirium in older patients, and medications are reserved for more severe symptoms that affect either medical management or patient safety.

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Delirium, defined as an acute disorder of attention and global cognitive function, is a common, serious, and potentially preventable source of morbidity and mortality for hospitalized older persons. Delirium affects as many as half of all people over age 65 who are hospitalized. With the aging of the US population, delirium has assumed heightened importance because persons aged 65 and older presently account for more than 45% of all days of hospital care. Delirium increases hospital costs by an average of $1000 per patient and posthospital ...

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