Delirium and Psychiatric Disorders in Older Adults
Delirium first
Delirium is an acute, fluctuating disturbance of attention and awareness, often with disorientation, hallucinations, or altered sleep-wake cycle. Use the Confusion Assessment Method (CAM): acute onset/fluctuation plus inattention, with disorganized thinking or altered consciousness. Predisposing factors include dementia, advanced age, sensory impairment, frailty, and polypharmacy; precipitants include infection, medications, pain, constipation, urinary retention, hypoxia, hypoglycemia, electrolyte disturbance, alcohol/benzodiazepine withdrawal, and surgery.
Nonpharmacologic prevention and treatment come first: reorientation, glasses and hearing aids, sleep hygiene, daytime mobility, hydration, pain control, bowel and bladder care, and caregiver presence. Antipsychotics are reserved for dangerous agitation or psychosis, at the lowest dose for the shortest time; benzodiazepines generally worsen delirium except in withdrawal.
Traps: missing hypoactive delirium and calling it depression or 'quiet'; treating asymptomatic bacteriuria; using physical restraints; and assuming a patient with dementia cannot also be delirious.
Depression in older adults may present with somatic complaints, pain, weight loss, or pseudodementia. Screen with PHQ-2/9 or GDS. Suicide risk is highest in older men; ask directly.
Worked example: a 90-year-old with hip fracture is agitated and pulling at lines on postoperative night 2. Think delirium: assess pain, urinary retention, constipation, hypoxia, and medications. Treat pain, restore orientation, avoid restraints, and reserve antipsychotics for severe symptoms.
Rule of thumb: any acute change in mental status in an older adult is delirium until proven otherwise.