Treatment of Delirium
The first-line treatment for delirium should focus on identifying and addressing underlying causes through a comprehensive assessment, while implementing non-pharmacological interventions, with antipsychotics reserved for severe symptoms when non-pharmacological approaches are insufficient. 1, 2
Diagnostic Assessment
- Diagnosis should be made by trained healthcare professionals using DSM or ICD criteria 1
- Assess for changes in:
- Cognitive function
- Emotional behavior
- Psychomotor activity
Management Algorithm
Step 1: Identify and Treat Underlying Causes
- Conduct comprehensive assessment to identify predisposing and precipitating factors 1
- Address reversible causes:
- Medications: Review and discontinue deliriogenic medications (steroids, anticholinergics) 2
- Infections: Treat infections according to patient's goals of care 1
- Metabolic abnormalities:
- Opioid neurotoxicity: Consider opioid rotation to fentanyl or methadone 1, 2
- Anticancer treatments: Consider medication or therapy withdrawal if related to chemotherapy or immunotherapies 1
Step 2: Non-Pharmacological Interventions
- Implement reorientation strategies 2
- Ensure cognitive stimulation 2
- Establish proper sleep hygiene 2
- Create calm environment with minimal unnecessary stimuli 2
- Consider early mobilization when patient is stable 2
- Provide 1:1 observation during acute phase 2
- Avoid physical restraints when possible as they may worsen delirium 2
Step 3: Pharmacological Management (for symptomatic relief when non-pharmacological approaches insufficient)
For Mild to Moderate Agitation:
- Oral antipsychotics 2:
- Haloperidol 2-5 mg
- Risperidone 0.5-2 mg
- Olanzapine 2.5-5 mg
- Quetiapine 25-50 mg (consider for patients with Parkinson's disease or Lewy body dementia)
For Severe Agitation/Hyperactive Delirium:
- Parenteral antipsychotics 2:
- Haloperidol 2-5 mg IV/IM (first-line)
- Olanzapine 5-10 mg IM
- Chlorpromazine (for bed-bound patients, monitor for hypotension)
For Refractory Agitation:
- Add benzodiazepines after therapeutic levels of antipsychotics have been achieved 2, 3:
- Lorazepam 1-2 mg IV/IM (preferred due to rapid onset, shorter duration, low risk of accumulation) 3
- Midazolam 2.5-5 mg IM/IV
Important Considerations and Caveats
- Avoid benzodiazepines as monotherapy except in alcohol or benzodiazepine withdrawal 2
- Monitor for antipsychotic side effects:
- QTc prolongation with haloperidol
- Extrapyramidal symptoms
- Hypotension with chlorpromazine 2
- Titrate medications to optimal relief while minimizing adverse effects 2
- Haloperidol advantages over other antipsychotics: multiple administration routes, fewer active metabolites, limited anticholinergic effects, lower sedative/hypotensive effects 3
- Atypical antipsychotics (risperidone, olanzapine) may have lower propensity for oversedation and movement disorders compared to typical antipsychotics 3
- Evidence is insufficient to recommend routine use of screening tools or delirium severity assessment tools 1
- Hydration considerations: Limited evidence for clinically assisted hydration in symptomatic management of delirium; decision should be made case-by-case 1
Special Populations
- Cancer patients: Delirium often reversible when related to medications or hypercalcemia; less reversible when due to infection 1
- Elderly patients: Higher risk for delirium (20% of hospitalized elderly); require careful medication selection and dosing 4
- Critically ill patients: Implement ABCDE approach (Awakening and Breathing Coordination, Delirium Monitoring, Early Mobility, and Exercise) 5
By systematically addressing underlying causes while providing appropriate symptomatic management, delirium can often be effectively treated, reducing its duration and associated complications.