From the Guidelines
Delirium management should prioritize addressing reversible causes, non-pharmacological interventions, and judicious use of medications, as outlined in the most recent guidelines from reputable sources such as the National Institute for Health and Clinical Excellence 1.
Key Steps in Delirium Management
- Identify and treat underlying causes such as infection, medication side effects, metabolic disturbances, or withdrawal states.
- Perform a thorough medical evaluation including physical examination, laboratory tests, and medication review.
- Implement non-pharmacological interventions including:
- Reorientation strategies (clocks, calendars, familiar objects)
- Ensuring adequate sleep-wake cycles
- Early mobilization
- Maintaining hydration and nutrition
- Addressing sensory impairments with glasses and hearing aids
- Involving family members when possible
- For pharmacological management, use medications sparingly and only when necessary for severe agitation or distress, with options including low-dose antipsychotics like haloperidol or atypical antipsychotics such as quetiapine or risperidone, as recommended by recent guidelines 1.
Prevention Strategies
- Early mobility
- Adequate hydration
- Sleep promotion
- Cognitive stimulation These approaches work by addressing the multifactorial nature of delirium, reducing neuroinflammation, restoring normal neurotransmitter function, and providing environmental stability that supports normal cognitive processing during this acute brain dysfunction, as supported by evidence from studies such as those published in the Annals of Internal Medicine 1.
From the Research
Delirium Management Steps
- Identify patients at risk for delirium, including those with advanced age, exposures to other stressors like infection, and certain medications 2
- Recognize patients with delirium and immediately identify and treat factors contributing to it 2
- Use multimodal strategies to prevent or attenuate delirium, improving patient outcomes 2
- Address underlying causes of delirium, such as pain, metabolic disturbances, and adverse environmental conditions 3, 4
- Prioritize nonpharmacologic measures for management, including the Tolerate, Anticipate, and Don't Agitate (TADA) approach and the Assess, Diagnose, Evaluate, Prevent, and Treat (ADEPT) tool 3
- Use the lowest effective dose of pharmacologic agents (atypical antipsychotics) for severe symptom control, if nonpharmacologic measures are unsuccessful 3
- Implement the ABCDEF bundle in intensive care units, which includes:
- Assess, prevent, and manage pain
- Both SAT and SBT
- Choice of analgesia and sedation
- Delirium: assess, prevent, and manage
- Early mobility and exercise
- Family engagement and empowerment 4
Pharmacologic Interventions
- Haloperidol may be used to manage delirium symptoms, but may slightly worsen delirium symptoms of mild to moderate severity compared with placebo 5
- Risperidone may slightly worsen delirium symptoms compared with placebo, and may increase extrapyramidal adverse events 5
- Quetiapine appears to be an effective and safe agent for the treatment of delirium, with equal efficacy compared to haloperidol and amisulpride 6
- Dexmedetomidine is under investigation as a potential pharmacologic intervention for delirium management 4