An elderly patient presents with fluctuating attention and confusion. What is the initial approach to management?

• A. Identify delirium and start antipsychotics immediately.
• B. Assess for delirium; identify underlying causes; ensure safety and minimize delirium-provoking medications.
• C. Assess for dementia and monitor daily activities.
• D. Discharge home with no further evaluation.

Answer: (B)

The main idea is recognizing delirium in an older adult and managing it by finding and treating its causes while keeping the patient safe. When there’s acute, fluctuating confusion and inattention, think delirium, not chronic dementia. The first step is to assess for delirium and look for what’s triggering it—infection, dehydration, electrolyte problems, hypoxia, pain, sleep disturbance, or medications that can provoke delirium (like anticholinergics, sedatives, or opioids). Along with identifying the cause, ensure safety and reduce exposure to medications that can worsen delirium. This includes minimizing sedatives and anticholinergic drugs, avoiding restraints if possible, and using environmental cues and assistance to orient and calm the patient. Quick workup is often needed to pinpoint reversible factors (basic labs, infection screens as indicated, and medication review). Addressing all identifiable contributors typically improves delirium, whereas simply labeling as dementia or discharging without evaluation does not address the acute problem.