What is the initial management of a patient presenting with acute delirium?

Initial Management of Acute Delirium

The initial management of acute delirium should focus on identifying and treating underlying causes while implementing non-pharmacological interventions before considering medication, as pharmacological interventions should be limited to patients with distressing symptoms or safety concerns. 1

Step 1: Assessment and Identification of Causes

• Perform targeted assessment within 24 hours of presentation to identify potential causes:

  • Metabolic disturbances (hypoglycemia, electrolyte abnormalities)
  • Infections (pneumonia, urinary tract infection, sepsis)
  • Medication effects (anticholinergics, sedatives, opioids)
  • Substance withdrawal (alcohol, benzodiazepines)
  • Hypoxia or respiratory failure
  • Cardiovascular issues (myocardial infarction, heart failure)
  • Neurological causes (stroke, intracranial hemorrhage, seizures)

• Consider neuroimaging if there is:

  • Suspicion of acute intracranial pathology
  • Focal neurological deficits
  • History of recent trauma
  • No other obvious cause identified 1

Step 2: Non-pharmacological Interventions

Implement a multicomponent intervention package immediately:

1. Ensure care continuity and environmental stability:

   • Maintain consistent healthcare team members
   • Avoid unnecessary room or ward transfers 1

2. Address cognitive impairment and disorientation:

   • Provide appropriate lighting (day/night cycle)
   • Ensure visible clocks and calendars
   • Use clear signage in the environment
   • Regularly reorient the patient (explain where they are, who you are)
   • Facilitate family visits 1

3. Address physiological needs:

   • Ensure adequate hydration
   • Monitor and manage constipation
   • Optimize oxygenation
   • Maintain appropriate nutrition 1

4. Promote normal sleep-wake cycles:

   • Reduce nighttime disruptions
   • Maintain daytime activity
   • Control noise and light levels 1

Step 3: Medication Review and Adjustment

• Discontinue or reduce medications that may contribute to delirium:

  • Anticholinergics
  • Benzodiazepines
  • Steroids
  • Certain opioids 1

• If opioid-associated delirium is suspected:

  • Consider opioid rotation to fentanyl or methadone
  • Reduce opioid dose by 30-50% when switching 1

Step 4: Pharmacological Management (Only if Necessary)

Pharmacological interventions should be reserved for:

• Patients with distressing symptoms (hallucinations, delusions)
• Safety concerns where patient poses risk to self or others 1

When medication is required:

1. For moderate delirium with distressing symptoms:

   • Olanzapine may offer benefit [III, C] 1
   • Quetiapine may offer benefit [V, C] 1
   • Aripiprazole may offer benefit [IV, C] 1

2. For severe agitation:

   • Consider benzodiazepines only for alcohol or benzodiazepine withdrawal 1
   • For other causes, atypical antipsychotics are preferred over haloperidol or risperidone, which have been shown to worsen symptoms in mild-to-moderate delirium 1

3. For hypoactive delirium:

   • Methylphenidate may improve cognition if no delusions or perceptual disturbances are present [V, C] 1

Important Caveats and Pitfalls

• Avoid haloperidol or risperidone as initial treatment for mild-to-moderate delirium as they have been shown to worsen symptoms [I, D] 1

• Use benzodiazepines cautiously as they:

  • Can worsen delirium
  • Are associated with increased fall risk
  • Should be reserved for alcohol/benzodiazepine withdrawal or crisis intervention 1

• Medication dosing principles:

  • Use lowest effective dose
  • Use for shortest time possible
  • Monitor closely for side effects 1

• Recognize delirium subtypes:

  • Hyperactive (agitation, restlessness)
  • Hypoactive (lethargy, reduced responsiveness) - often underdiagnosed 1
  • Mixed

• Address family and caregiver needs:

  • Provide education about delirium
  • Offer emotional support
  • Include in reorientation strategies 1

By following this algorithmic approach that prioritizes identification and treatment of underlying causes, implementing non-pharmacological interventions, and using medications judiciously only when necessary, you can effectively manage acute delirium while minimizing complications and improving outcomes.