What are the guidelines for managing delirium?

Guidelines for Managing Delirium

Delirium management should focus on a multicomponent intervention package that addresses modifiable risk factors, with prevention being the most effective strategy that can prevent approximately one-third of all delirium episodes. 1

Identification and Assessment

• Diagnosis should be made by trained healthcare professionals using clinical assessment based on DSM or ICD criteria 1
• Watch for key features: recent onset of fluctuating awareness, impaired memory/attention, and disorganized thinking 1
• If cognitive, emotional, or psychomotor changes suggestive of delirium are present, a thorough clinical assessment is needed 1
• High-risk groups requiring targeted prevention include:
  • Persons aged 65 years or older
  • Patients with cognitive impairment or dementia
  • Patients with severe illness
  • Patients with current hip fracture 1

Prevention Strategies

Prevention is more effective than treatment, with evidence suggesting about one-third of delirium cases are preventable through risk factor modification 1. Key preventive interventions include:

1. Environmental Stability

   • Minimize patient transfers between units
   • Maintain consistent care teams
   • Reduce excessive noise in hospital wards
   • Promote person-centered care approaches 1

2. Multicomponent Intervention Package

   • Address cognitive impairment/disorientation through:
     • Orienting communication
     • Cognitive stimulation
     • Therapeutic activities
   • Prevent dehydration and constipation
   • Address hypoxia
   • Treat infections promptly
   • Promote early mobilization and walking
   • Review medications regularly
   • Manage pain effectively
   • Ensure adequate nutrition
   • Address sensory impairment with adaptive equipment
   • Implement nonpharmacological approaches to improve sleep 1

Management of Established Delirium

When delirium occurs, management should focus on:

1. Identifying and Treating Underlying Causes

   • Conduct comprehensive assessment to identify precipitating factors 1
   • Address specific causes:
     • Consider opioid rotation if opioid-induced neurotoxicity is suspected 1
     • Treat infections if appropriate to patient's goals of care 1
     • Use bisphosphonates for hypercalcemia-induced delirium 1
     • Correct electrolyte abnormalities (particularly hypomagnesemia) 1
     • Discontinue medications that may be contributing to delirium 1

2. Pharmacological Management

   • No medications are FDA-approved specifically for delirium treatment 2
   • Antipsychotics are commonly used but evidence is limited:
     • Newer atypical antipsychotics (olanzapine, quetiapine, risperidone) are generally preferred over haloperidol 3
     • Use should be targeted and time-limited 2
   • Alpha-2 agonists like dexmedetomidine may be beneficial in ICU settings 2, 3
   • Avoid medications that can worsen delirium (benzodiazepines, anticholinergics) 2

3. Nonpharmacological Approaches

   • Implement the ABCDE approach in critical care settings:
     • Awakening and Breathing Coordination
     • Delirium Monitoring
     • Early Mobility
     • Exercise 2
   • Ensure adequate sleep hygiene
   • Provide reorientation strategies
   • Involve family members in care 4

Healthcare Team Education

• Interprofessional delirium education interventions should be a core component of unit- or hospital-wide strategies 1
• Education should focus on recognition, assessment, and management skills
• Training has been shown to improve healthcare provider knowledge and confidence in managing delirium 1

Common Pitfalls to Avoid

1. Underrecognition: Delirium is frequently missed or misdiagnosed, especially hypoactive forms
2. Overreliance on medications: Pharmacological interventions should be second-line after addressing underlying causes and implementing nonpharmacological approaches
3. Environmental disruption: Frequent transfers between units can worsen delirium
4. Inconsistent implementation: Prevention requires high-fidelity implementation of all components of the intervention package, not just selective elements 1
5. Neglecting education: Healthcare teams need specific training to recognize and manage delirium effectively 1

The implementation of these guidelines requires systematic approaches that support comprehensive and reliable delivery of specific tasks, going beyond well-trained staff to include healthcare systems that facilitate proper delirium prevention and management.