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