When evaluating for delirium, search for the cause and any possible precipitating factors, advised Dr. Palmer: “Consider multiple etiologies, and remember that fluctuation in the course is the rule.” Eliminating precipitating factors can help. Evaluation should include a targeted history and physical, and lab work to check things like drug levels and neuroimaging.
You may be able to manage delirium with nonpharmacologic changes in environment such as adding orienting stimuli of clocks, TV, and personal items; minimizing abrupt relocations; and sitting the patient in an upright position. You can also increase sensory input, said Dr. Palmer. You may also try a short course of meds: For severe agitation, haloperidol (0.5 to 1 mg every four hours as needed) or for anxiety symptoms use lorazepam (0.5 to 1 mg every four to six hours as needed).
Dr. Palmer offered a partial list of medications to avoid for elderly patients. “These patients are very vulnerable to bad outcomes,” he warned. His list included:
- Trimethobenzamide; and
- Famotidine (high dose).
Additionally, you should be aware that the following classes of drugs could cause delirium in the elderly:
- Antianxiety medications;
- Antipsychotics; and
- Anti-inflammatory medications.
“Basically, any pharmacological class that begins with ‘anti’ should be avoided with elderly patients,” said Dr. Palmer.
Assess and Manage Undernutrition
An astonishing 40% to 60% of hospitalized, ill elderly patients suffer from malnutrition.
“This is often not diagnosed or adequately treated,” said Dr. Palmer. “It’s associated with terrible outcomes of hospital care, including length of stay, mortality, and affected ADL activities.”
There is no single blood test for malnutrition, Dr. Palmer continued, but indicators include a body mass index of less than 19, reduced muscle mass, reduced skin fold thickness, and biochemical measures including serum albumin of less than three and low hemoglobin and serum cholesterol.
To guard against dehydration and undernutrition in your elderly patients, Dr. Palmer advised assessing nutritional status at admission, prescribing and monitoring daily calorie and fluid intake for high-risk patients, giving priority to providing calories over restricted diet, and including consultation with a dietitian.
Take off the Restraints
“Why do we order bed rest for the weak and sick?” asked Dr. Palmer. He urged hospitalists to avoid bed-rest orders and instead encourage elderly patients to get out of bed and get physical activity or even physical therapy for transfer-dependent and gait-impaired patients.
Most of all, he said, “Avoid physical restraints.” These limit mobility, obviously, and can lead to pressure ulcers, deconditioning, falls, constipation, and incontinence.
Where to Send the Patient
Plan for discharging an independent elderly patient back home, not to a nursing home if you can, urged Dr. Palmer.
“Comprehensive discharge planning almost always requires an interdisciplinary team,” he said. “Goals of care and advanced directives should be discussed with the patient and family members, and post acute care needs should be considered.”
Following a “functional trajectory” from admission to discharge begins the first day. Dr. Palmer recommends the hospitalist, a nurse, and the case manager all interview the patient and family, establish a baseline and outline the expected hospital course including estimated length of stay and discharge site—nursing home, skilled nursing facility, or home.