What is the diagnostic workup and treatment for delirium (Delerium)

From the Guidelines

Delirium diagnosis and treatment should prioritize a systematic approach, starting with identification of the condition through clinical assessment using validated tools like the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or Intensive Care Delirium Screening Checklist (ICDSC), as recommended by the most recent guidelines 1. To diagnose delirium, the following steps should be taken:

• Evaluate for acute onset of fluctuating attention, disorganized thinking, and altered level of consciousness
• Obtain a thorough history, focusing on medication changes, recent illnesses, and baseline cognitive function
• Conduct a comprehensive physical examination and order appropriate laboratory tests, including complete blood count, comprehensive metabolic panel, urinalysis, blood cultures, and toxicology screening
• Brain imaging (CT or MRI) may be necessary if neurological causes are suspected Treatment involves addressing the underlying cause while implementing non-pharmacological interventions, such as:
• Maintaining a normal sleep-wake cycle
• Providing orientation cues
• Ensuring adequate hydration
• Involving family members For severe agitation that poses safety risks, low-dose antipsychotics may be used cautiously, with haloperidol 0.5-1mg orally or intramuscularly being a recommended option, as stated in the guidelines 1. Benzodiazepines should generally be avoided except in alcohol withdrawal delirium, where lorazepam 0.5-1mg every 4-6 hours may be appropriate. It is essential to note that delirium management is urgent, as the condition increases mortality risk, prolongs hospitalization, and may lead to long-term cognitive impairment, with prevention being equally important through regular orientation, early mobilization, and minimizing unnecessary medications 1.

From the Research

Diagnosis of Delirium

• Delirium is characterized by acute, fluctuating altered levels of consciousness, inattention, and cognitive function disorders 2
• The diagnosis is clinical but can be challenging due to overlapping symptoms with dementia and depression 3
• The Confusion Assessment Method (CAM) is a screening tool that is 94% to 100% sensitive for detecting delirium 3

Assessment Scales for Delirium

• The Confusion Assessment Method (CAM) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) are validated instruments for the diagnosis of delirium 4, 5
• The Delirium Rating Scale-Revised-98 (DRS-R-98) and the Delirium-O-Meter (DOM) are also used for monitoring the course of delirium 2
• The Intensive Care Delirium Screening Checklist (ICDSC) has moderate sensitivity and good specificity for diagnosing delirium in critically ill patients 5

Risk Factors for Delirium

• Older age, multiple comorbidities, recent surgery, and polypharmacy are independent risk factors for delirium 3
• Metabolic and electrolyte disturbances are also predisposing and precipitating factors for delirium 2

Treatment and Management of Delirium

• Haloperidol and new antipsychotic drugs are recommended pharmacological treatment methods for delirium 2, 3
• Non-pharmacological interventions, such as routine screening of cognitive functions and comprehensive medical and nursing care, are also recommended 2
• Prevention and early detection of delirium are crucial, as patients hospitalized with prolonged delirium have a higher risk of mortality 3