Therapeutic Advances in the Prevention and Treatment of Delirium in the Hospital Setting

Background: Delirium is one of the most common, costly, and devastating complications affecting up to 56% of hospitalized older patients, with an associated hospital mortality rate of 25%-33%, and annual health care expenditures exceeding $152 billion. Areas of Uncertainty: Despite its high prevalence and poor outcomes, there is a significant gap in therapeutic interventions for the prevention and treatment of delirium. Therapeutic Interventions: Nonpharmacologic multicomponent prevention interventions such as the hospital elder life program (HELP) and early mobilization and reorientation remain first line, and they have consistently demonstrated a reduction in the incidence of delirium. There is currently no evidence to support the use of antipsychotics, cholinesterase inhibitors, or psychostimulants for the prevention of delirium across all health care settings, including the intensive care unit. Avoiding sedation, and specifically benzodiazepines, is an important modality to prevent delirium. Given the lack of evidence to support the use of antipsychotics along with the adverse event profile, including a black box warning for an increase in cardiovascular mortality, these medications should only be used for the treatment of delirium with features of severe agitation and psychosis. In the intensive care unit setting, dexmedetomidine in lieu of propofol or other classic sedatives may prevent and shorten the duration of delirium. Finally, dexmedetomidine and general anesthetics, such as sevoflurane and desflurane, are being evaluated in the prevention and treatment of postoperative delirium. Conclusion: Multicomponent nonpharmacologic interventions are currently the most effective modality for the prevention and treatment of delirium.