Australian and New Zealand Society for Geriatric Medicine: Position Statement – Sleep in the older person.

of impaired attention that fluctuates, together with impaired cognition and/or altered consciousness, perceptual disturbances and behaviour. It may be the only sign of serious medical illness in an older person and should be urgently assessed. Misdiagnosis of delirium may have dire consequences. 2 Better prevention and treatment are needed to avoid the poor outcomes that result from delirium, especially increased rates of cognitive and functional decline, prolonged hospital stay, institutionalisation and mortality. 3 All older persons should be assessed for risk factors for delirium on admission to hospital. These include dementia, polypharmacy, visual and hearing impairment, dehydration, functional disability, alcohol abuse, depression and advanced age. Many precipitating factors exist, including iatrogenesis, particularly from medications: these are unfortunately common and potentially avoidable. 4 Delirium is very common but is often not detected or is misdiagnosed. Cognition should be considered a ‘vital sign’ and cognitive assessment routinely performed. Those who display altered cognition should be screened for delirium using a tool such as the Confusion Assessment Method. 5 Preventative strategies have been demonstrated to be very effective. These are based on multicomponent interventions targeting risk factors that are managed with care protocols and environmental strategies. 6 Education programs are very effective in prevention. Preventative strategies and education programs should be adopted by all health-care institutions. 7 Investigations for common precipitating factors are usually needed unless clear, recent causes are identified. Specialised investigations may be needed in specific circumstances. 8 Management of delirium involves identifying and treating risk factors and precipitating factors, use of nonpharmacological and pharmacological measures to manage neuropsychiatric manifestations, preventing complications and monitoring progress. 9 Non-pharmacological measures should always be utilised. These include: correction of dehydration (subcutaneous fluids if needed), malnutrition and sensory deficits; provision of reorientation, good quality communication and undisturbed sleep; encouraging self-care and mobility; avoiding use of restraints or immobilising devices; and limiting room and staff changes where relevant. 10 Pharmacological measures are not always needed but should be considered to control distressing symptoms or when safety is compromised. Small doses of antipsychotics are effective and appropriate in the short term. When patients with an extrapyramidal syndrome require treatment, atypical antipsychotics should be considered. Benzodiazepines are useful in alcohol and benzodiazepine withdrawal. 11 Delirium is best managed by a multidisciplinary team utilising multicomponent interventions in an appropriate environment with adequate staffing levels. Delirium units provide effective and safe care for older people, can help raise awareness of delirium as a serious condition and enhance delirium research. They are costeffective but there is no evidence to suggest that such units produce better outcomes than acute care of the elderly units.