Figure 1: hospital based screening for high risk for delirium development:

Malaz Boustani, MD, MPH
Indiana University Center for Aging Research the IUCAR-DSM Protocol
Delirium Screening and Management Protocol
Figure 1: Hospital based screening for high-risk patients for delirium development. Risk factors
Calculating risk:
Intervention for those with at least moderate risk of
developing delirium
Low (<2%): Total score = 0 or 1.
Administer the 6 item screener and if pt make one error consider MMSE or geriatric evaluation. If Dementia present continue or initiate Moderate (10-20%): Total score = 2 or 3
If H/o ETOH present prevent ETOH withdrawal High (25-50%): total score = 4 or 5.
Very high (>50%): Total score >5
Prevent peri-operative pain and constipation interventions and or 25 mg po qhs of Trazodone Data are based on estimates driven form literature review on dementia in surgical and non-surgical elderly population. Please don’t copy or disseminate without permission from Dr. Boustani 317-630-7200/ [email protected]
Malaz Boustani, MD, MPH
Indiana University Center for Aging Research the IUCAR-DSM Protocol
Delirium Screening and Management Protocol
Figure 2: Diagnosing delirium.
Source of data Acute change &
Attention deficit
Disorganized thinking
Hyper or hypo Alert status
Fluctuating course
Impression of
caregiver
Patient
Can’t spell his first z Incoherent speech examination
mental status between different examiners or Variation in pts Mental status throughout the day Consider delirium present if pt had acute change and attention deficit plus problem in thinking or alert status. Please don’t copy or disseminate without permission from Dr. Boustani 317-630-7200/ [email protected]
Malaz Boustani, MD, MPH
Indiana University Center for Aging Research the IUCAR-DSM Protocol
Delirium Screening and Management Protocol
Figure 3: Hospital based general delirium management protocol. Provider
Intervention
Create delirium Room:
z
Orient pts about his place, the reason of hospitalization, and provide large clock and calendar Allow a sleeping period of at least 4-6 hr at night Encourage decorating the room with personal item. Recognize and treat pain and constipation Encourage out of bed activity if possible Clear path from bed to bathroom or provide bedside commode at night. Provide pt with glass and hearing aid if needed. Manage constipation if no BM within 1 day Manage pain with RTC dosage instead of PRN Please don’t copy or disseminate without permission from Dr. Boustani 317-630-7200/ [email protected]
Malaz Boustani, MD, MPH
Indiana University Center for Aging Research the IUCAR-DSM Protocol
Delirium Screening and Management Protocol
Figure 4: Hospital based specific delirium management protocol. Symptoms
Assessment
Intervention
Hyperactivity or agitaiton z √ Pulse, BP, T,
Assess the impact of agitaiton on pt safety and d/c Foley if possible If h/o ETOH consider Lorazepam 0.25- 0.5 mg PO/IM/IV q 4-6 hr If safety become an issue, sitter failed to ameliorate agitaiton, and reversing underlying medical condition is in process, then consider using Haloperidol 0.25 mg PO/IM/IV q 4 hr Prn for max dose of 2 Hypo activity
Insomnia
Evaluate for pain and consider RTC pain meds Evaluate for underlying depressive disorder and start on SSRI if depression is present.
References:
Marcantonio ER. Goldman L. Mangione CM. Ludwig LE. Muraca B. Haslauer CM. Donaldson MC. Whittemore AD. Sugarbaker DJ. Poss R.
et al. A clinical prediction rule for delirium after elective noncardiac surgery.JAMA. 271(2):134-9, 1994 Jan 12.
Marcantonio ER. Flacker JM. Wright RJ. Resnick NM. Reducing delirium after hip fracture: a randomized trial. Journal of the American
Geriatrics Society. 49(5):516-22, 2001 May.
Flacker JM. Marcantonio ER. Delirium in the elderly. Optimal management. Drugs & Aging. 13(2):119-30, 1998 Aug.
Inouye SK. Bogardus ST Jr. Charpentier PA. Leo-Summers L. Acampora D. Holford TR. Cooney LM Jr. A multicomponent intervention to
prevent delirium in hospitalized older patients. New England Journal of Medicine. 340(9):669-76, 1999 Mar 4.
Boustani M, Shah A, Heck D, Farlow M, et al. Management of Delirium in Hospitalized elderly. Presented at the Annual Meeting of American
Geriatric Psychiatry 2004, Baltimore, MD.
Please don’t copy or disseminate without permission from Dr. Boustani 317-630-7200/ [email protected]

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