Initial Workup and Management of Delirium
The initial workup for delirium must include a validated screening tool (such as the Confusion Assessment Method), comprehensive evaluation for underlying causes, and immediate implementation of non-pharmacological interventions while treating the underlying etiology. 1, 2
Diagnosis and Assessment
Screening and Identification
- Use validated screening tools:
Key Diagnostic Features
- Acute onset and fluctuating course
- Inattention (cardinal feature)
- Altered level of consciousness
- Disorganized thinking 1, 2
Delirium Subtypes
- Hyperactive: agitation, restlessness, combativeness
- Hypoactive: lethargy, decreased responsiveness (often missed but associated with higher mortality) 1, 2
- Mixed: fluctuating between both states 2
Comprehensive Workup
Laboratory Investigations
- Complete blood count
- Comprehensive metabolic panel (electrolytes, renal function, liver function)
- Urinalysis and urine culture
- Blood cultures if infection suspected
- Arterial blood gas if respiratory distress
- Toxicology screen
- Thyroid function tests
- Vitamin B12, folate levels 1, 2
Imaging Studies
- Head CT without contrast as first-line neuroimaging for most patients 1
- Consider MRI if:
- Focal neurological deficits
- History of cancer
- Suspected encephalitis 1
Additional Testing Based on Clinical Suspicion
- Electrocardiogram for cardiac evaluation
- Chest radiography to assess for pneumonia
- Electroencephalography if seizure activity suspected
- Lumbar puncture if central nervous system infection suspected 1
Common Underlying Causes to Identify
Medical Conditions
- Infections (UTI, pneumonia most common) 1
- Metabolic disturbances (electrolyte abnormalities, hypoglycemia)
- Organ dysfunction (liver, kidney)
- Hypoxia
- Cardiovascular disease (MI, stroke, heart failure) 2
Medication-Related
- Review all medications, especially:
Substance-Related
Management Approach
Non-Pharmacological Interventions (First Line)
- Reorientation strategies (clocks, calendars, familiar objects)
- Environmental modifications (adequate lighting, reduce noise)
- Sensory support (ensure eyeglasses, hearing aids available)
- Early mobilization
- Sleep-wake cycle regulation
- Family involvement 1, 2
Pharmacological Management (Only if Necessary)
- Use medications only when non-pharmacological measures are insufficient and patient presents severe symptoms that pose safety risks 2
- First-line agent: Haloperidol (low dose)
- Avoid in Parkinson's disease or Lewy body dementia 4
- Alternative agents:
Prevention Strategies
ABCDEF Bundle Implementation
- Assess and manage pain
- Both spontaneous awakening and breathing trials
- Choice of appropriate analgesia/sedation
- Delirium assessment, prevention, management
- Early mobility
- Family engagement 2
Common Pitfalls to Avoid
- Underrecognition of hypoactive delirium (often missed but carries worse prognosis) 2
- Overreliance on medications without addressing underlying causes
- Failure to implement non-pharmacological interventions
- Inadequate monitoring of medication side effects
- Environmental disruption (frequent room changes, restraints) 2
Follow-Up and Monitoring
- Reassess regularly using validated tools
- Monitor response to interventions
- Document episode in medical record
- Communicate delirium occurrence to outpatient providers
- Educate patient and family about delirium 2, 3
Delirium is a medical emergency with significant impact on morbidity and mortality. Early recognition, identification of underlying causes, and prompt intervention are essential to improve outcomes and reduce complications 1.