What is the best practice for managing delirium?

From the Guidelines

The best practice for managing delirium involves a multimodal approach that prioritizes non-pharmacological interventions before considering medications. This approach is supported by the most recent and highest quality study, which emphasizes the importance of identifying and treating underlying causes, implementing environmental modifications, and promoting early mobility and family presence 1.

Some key components of this approach include:

• Identifying and treating underlying causes such as infections, metabolic disturbances, or medication side effects
• Implementing environmental modifications, including maintaining a well-lit room during the day and darkness at night, providing orientation cues (clocks, calendars), ensuring adequate hydration and nutrition, promoting early mobility, and encouraging family presence
• Avoiding antipsychotics and benzodiazepines for first-line treatment of delirium unless benefits far outweigh known risks and there is an active risk of harm to the patient or staff
• Using multicomponent, nonpharmacologic interventions that focus on reducing modifiable risk factors for delirium, improving cognition, and optimizing sleep, mobility, hearing, and vision in critically ill adults 1

For pharmacological management, avoid benzodiazepines except in alcohol withdrawal cases. If medications are necessary for severe agitation or distress, low-dose antipsychotics like haloperidol (0.5-1mg orally or IM) or quetiapine (25-50mg orally) can be used short-term with careful monitoring for side effects 1.

Regular reassessment using validated tools like CAM or CAM-ICU helps monitor response to interventions. This comprehensive approach addresses delirium's multifactorial nature, targeting the disruption in neurotransmitter systems and brain connectivity while minimizing complications and promoting faster recovery.

From the Research

Best Practice for Delirium Management

The best practice for managing delirium involves a combination of non-pharmacologic and pharmacologic interventions.

• Non-pharmacologic interventions are considered the first-line approach for both prevention and treatment of delirium 2.
• The ABCDEF bundle, which includes assessing and managing pain, both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT), choice of analgesia and sedation, delirium assessment and management, early mobility and exercise, and family engagement and empowerment, has been shown to reduce the odds of developing delirium and the need for mechanical ventilation 3, 4.
• Multicomponent non-pharmacologic interventions have been found to be efficacious in non-ICU populations, and their adoption in the ICU has shown potential benefits in delirium outcomes 3.

Pharmacologic Interventions

• Antipsychotics, such as haloperidol, were previously considered the mainstay of delirium treatment, but recent guidelines suggest against their routine use in critically ill adults due to the risk of significant side effects, particularly in the elderly 2, 4, 5.
• Other pharmacologic agents, such as dexmedetomidine, have shown promising results, but more data is needed to definitively recommend their use 3, 4.
• The use of validated delirium screening instruments, such as the Confusion Assessment Method (CAM), can aid in accurately identifying cases of delirium 2, 6.

Education and Awareness

• Educational interventions, such as multifaceted intervention packages, can improve delirium recognition and management by increasing knowledge and use of delirium screening tools among healthcare professionals 6.
• Challenging common misconceptions about delirium can also improve patient care, quality of life, and clinical outcomes 2.