Which of the following best describes the best initial management of delirium in elderly patients?

• A. Identify and treat underlying causes, minimize delirium-inducing medications, and ensure sleep.
• B. Increase sedation and sleep aids to calm the patient.
• C. Initiate broad-spectrum antibiotics immediately.
• D. Isolate the patient and restrict mobility.

Answer: (C)

Delirium in older adults is an acute, fluctuating disturbance of attention and cognition driven by multiple reversible factors. The best initial approach is to identify and address those factors while minimizing things that worsen delirium. Start with a careful medication review and stop or reduce drugs known to precipitate delirium, such as anticholinergics, benzodiazepines, certain sedatives, and opioids when possible. Ensure the patient is well hydrated, nourished, and pain is controlled; correct electrolyte imbalances and metabolic abnormalities; and optimize oxygenation.

Create a calm, well-lit environment with regular day–night cues to support sleep and orientation, and avoid restraints. Obtain appropriate tests to uncover reversible causes (basic labs, glucose, renal and liver function, thyroid tests, B12/folate as needed, urinalysis and cultures if infection is suspected, chest imaging or other studies guided by symptoms). Treat infections or other identified conditions if they are present, but antibiotics should not be started solely to treat delirium without evidence of an infectious process. If agitation occurs and safety is a concern, use short-term, low-dose pharmacologic agents only after nonpharmacologic measures have been tried. The focus is on removing triggers and stabilizing the patient, not on routine use of antibiotics or sedatives.