How is hospital delirium managed?

From the Guidelines

Hospital delirium is best managed through a tailored, multicomponent intervention package delivered by a multidisciplinary team within 24 hours of hospitalization, as recommended by the National Institute for Health and Clinical Excellence guideline 1. This approach involves assessing patients at risk for clinical factors contributing to delirium and providing personalized interventions based on their individual needs and care setting. Key components of this package include:

• Ensuring continuity of care by minimizing changes in surroundings and staff, as frequent changes can contribute to feelings of disorientation and confusion 1
• Addressing cognitive impairment or disorientation by providing appropriate lighting, clear signage, and ensuring that clocks and calendars are easily visible to the patient 1
• Implementing environmental modifications to reduce confusion, such as maintaining a quiet room with familiar objects and family presence
• Identifying and treating underlying causes of delirium, including infections, metabolic disturbances, medication effects, or withdrawal
• Reserving pharmacological management for severe agitation that poses safety risks, and using low-dose antipsychotics such as haloperidol, quetiapine, or risperidone short-term while monitoring for side effects The ABCDEF bundle (Assess for pain, Both spontaneous awakening and breathing trials, Choice of sedation, Delirium monitoring, Early mobility, and Family engagement) has also shown effectiveness in reducing delirium in intensive care settings, although it is not specifically mentioned in the provided guideline 1. By prioritizing a multidisciplinary and personalized approach to delirium management, healthcare teams can reduce the risk of delirium, improve patient outcomes, and enhance quality of life 1.

From the Research

Hospital Delirium Management

• Hospital delirium is an acute change in awareness and attention that is common, morbid, and costly for patients and health care systems 2
• Management of hospital delirium involves three critical steps: identifying patients at risk, developing a systematic approach to prevent delirium, and assessing and managing delirium in a standardized fashion 2

Identification and Prevention

• Delirium risk can be assessed using known patient-based and illness-based risk factors, including preexisting cognitive impairment 2
• Tools such as the modified Richmond Agitation and Sedation Scale can aid in monitoring for changes in mental status that could indicate the development of delirium 2
• Multimodal nonpharmacologic delirium prevention methods can be used to prevent delirium, and high-risk patients should be monitored for its occurrence 2

Assessment and Management

• Delirium diagnosis remains a clinical diagnosis that requires a clinical assessment that can be structured using diagnostic criteria 2
• The key to managing delirium lies in addressing the underlying cause/causes of delirium, which often involve medical conditions or medications 2
• Antipsychotics such as haloperidol, risperidone, olanzapine, and aripiprazole can be used to manage delirium, but their use should be judicious and based on consensus panel guidelines 3, 4, 5
• Nonpharmacologic interventions should be prioritized early, and antipsychotics should only be used when necessary and in accordance with evidence-based guideline recommendations 6

Antipsychotic Use

• Haloperidol, risperidone, olanzapine, and aripiprazole have been shown to be equally effective in managing delirium, but they differ in terms of their side-effect profile 5
• Extrapyramidal symptoms are most frequently recorded with haloperidol, and sedation occurs most frequently with olanzapine 5
• Antipsychotic use in delirium care is a risk for adverse health outcomes and a longer duration of delirium, especially in older people 6