What are the steps for managing acute delirium?

Management of Acute Delirium

The management of acute delirium should prioritize non-pharmacological interventions first, followed by targeted pharmacological treatment only for distressing symptoms or safety concerns, while simultaneously addressing underlying causes. 1

Diagnosis and Assessment

• Use validated screening tools for early detection:

  • Confusion Assessment Method (CAM)
  • CAM-ICU (for intensive care settings)
  • Intensive Care Delirium Screening Checklist (ICDSC) 2, 1

• Look for key diagnostic features:

  • Acute onset and fluctuating course
  • Inattention
  • Disorganized thinking
  • Altered level of consciousness 1

Step 1: Identify and Treat Underlying Causes

• Medical causes:

  • Infections (especially UTI, pneumonia)
  • Metabolic disturbances (electrolyte imbalances)
  • Hypoxia
  • Pain
  • Dehydration
  • Constipation/urinary retention 1

• Medication-related causes:

  • Review all medications for deliriogenic potential
  • For opioid-associated delirium: reduce dose or switch to fentanyl or methadone (with 30-50% equianalgesic dose reduction) 2
  • Consider deprescribing high-risk medications 2

Step 2: Implement Non-Pharmacological Interventions

• Environmental modifications:

  • Minimize transfers between units
  • Maintain consistent care teams
  • Reduce noise
  • Ensure proper lighting (bright during day, dim at night) 1

• Cognitive support:

  • Frequent reorientation
  • Use orientation boards with date, location, and care team
  • Visible clocks 1

• Sensory optimization:

  • Ensure eyeglasses and hearing aids are available and used
  • Check for impacted ear wax 1

• Mobility interventions:

  • Encourage early mobilization as allowed by patient's condition
  • Provide walking aids if needed
  • Avoid unnecessary urinary catheterization
  • Avoid physical restraints 1, 2

• Sleep-wake cycle regulation:

  • Increase daylight exposure during day
  • Discourage daytime napping
  • Use evening relaxation protocols
  • Minimize nighttime disruptions, noise, and light 1

Step 3: Pharmacological Management (Only When Necessary)

Only use medications if the patient shows distressing symptoms (like hallucinations or delusions) or poses safety risks to self or others 2, 1

First-line options:

• For hyperactive delirium with distressing symptoms:

  • Atypical antipsychotics preferred:
    • Olanzapine [III, C] 2
    • Quetiapine [V, C] 2
    • Aripiprazole [IV, C] 2

• Important cautions:

  • Haloperidol and risperidone have no demonstrable benefit in mild-to-moderate delirium and are not recommended [I, D] 2
  • Use lowest effective dose for shortest time possible
  • Monitor closely for effectiveness and adverse effects 1

Special situations:

• For hypoactive delirium with no delusions/hallucinations: Methylphenidate may improve cognition [V, C] 2

• For severe agitation with safety concerns:

  • Benzodiazepines (midazolam, lorazepam) can provide sedation [II, C]
  • Note: Benzodiazepines should be avoided as first-line agents except for:
    • Alcohol/benzodiazepine withdrawal
    • When antipsychotics fail 2

Step 4: Family Education and Support

• Provide clear information about delirium to family members
• Explain that delirium is often temporary and potentially reversible
• Involve family in reorientation strategies
• Address family distress and provide emotional support 1

Common Pitfalls to Avoid

• Underrecognition of hypoactive delirium - appears as lethargy rather than agitation but equally serious 1
• Overreliance on medications - can worsen delirium; should be second-line after non-pharmacological approaches 1
• Failure to address reversible causes - thorough investigation of underlying factors is essential 1
• Environmental disruption - frequent transfers between units can worsen delirium 1
• Inadequate monitoring - delirium fluctuates and requires ongoing assessment 1

ABCDEF Bundle for ICU Delirium Prevention

Implementation of this evidence-based bundle has been associated with reduced delirium and improved outcomes 2:

• A: Assess, prevent, and manage pain
• B: Both spontaneous awakening trials and spontaneous breathing trials
• C: Choice of analgesia and sedation (prefer non-benzodiazepines)
• D: Delirium: assess, prevent, and manage
• E: Early mobility and exercise
• F: Family engagement and empowerment 2, 3

Remember that prevention is more effective than treatment, with evidence suggesting about one-third of delirium cases are preventable through risk factor modification 1.