How to manage a patient with delirium?

From the Guidelines

Managing a patient with delirium requires a comprehensive approach focusing first on identifying and treating underlying causes while providing supportive care, with non-pharmacological interventions as the first-line treatment, as recommended by the most recent guidelines 1.

Key Components of Management

• Conduct a thorough medical evaluation to identify triggers such as infection, metabolic disturbances, or medication side effects.
• Implement non-pharmacological interventions:
  • Maintain a consistent daily routine.
  • Ensure adequate lighting during the day and darkness at night.
  • Place familiar objects in the room.
  • Encourage family presence.
  • Provide frequent reorientation with clocks and calendars.
• Address basic needs including hydration, nutrition, pain control, and early mobilization.

Pharmacological Management

For severe agitation that poses safety risks, consider short-term pharmacological management with low-dose antipsychotics such as haloperidol or quetiapine, but prophylactic treatment with haloperidol for ventilated patients should not be implemented as it shows no effect in incidence, severity, duration, or outcome of delirium 1.

• Benzodiazepines should generally be avoided except in alcohol withdrawal delirium.

Patient Safety and Education

• Ensure patient safety through fall prevention measures, avoiding physical restraints when possible, and maintaining close observation.
• Delirium management is most effective when addressing the fluctuating nature of symptoms through consistent approaches across all healthcare team members and family education about the condition's temporary nature and appropriate interaction techniques.

Recent Guidelines

The most recent guideline on multimodal rehabilitation for patients with post-intensive care syndrome emphasizes the importance of non-pharmacological interventions for delirium prevention, including multimodal sensory, cognitive, and emotional stimulation, and recommends against the prophylactic use of haloperidol 1.

From the Research

Management of Delirium

To manage a patient with delirium, several strategies can be employed:

• Identify and address potentially modifiable risk factors, as suggested by 2
• Use well-validated delirium screening tools to reliably detect delirium, as recommended by 2
• Implement nonpharmacologic strategies to reduce sensory impairment, sleep deprivation, and immobility, as supported by 2
• Consider the use of the "ABCDEF bundle" to reduce delirium, as indicated by 2

Pharmacologic Treatment

Pharmacologic treatment options for delirium include:

• Antipsychotics, such as haloperidol, risperidone, olanzapine, and quetiapine, as discussed in 3, 4, and 5
• However, pharmacologic treatment with antipsychotics is not supported by findings from placebo-controlled trials, as noted by 2
• Low-dose haloperidol may be effective in decreasing the degree and duration of delirium in post-operative patients, as found by 4
• Quetiapine has been shown to be a safe and effective treatment for delirium in older adults, as reported by 5

Nonpharmacologic Interventions

Nonpharmacologic interventions can aid in the management of delirium, including:

• Reducing sensory impairment, as suggested by 2
• Minimizing sleep deprivation, as recommended by 2
• Promoting mobility, as supported by 2
• Providing optimal levels of stimulation, reorienting patients, education, and supporting families, as discussed in 6

Diagnosis and Assessment

Diagnosis and assessment of delirium can be aided by:

• Using DSM-IV criteria, the Delirium Symptom Interview, or the confusion assessment method, as outlined in 6
• Ruling out dementia and depression, determining the presence of delirium, and establishing an underlying cause, as recommended by 3