What is the treatment for delirium?

Delirium Treatment

The cornerstone of delirium treatment is identifying and addressing underlying causes while implementing non-pharmacological interventions as first-line management, with medications reserved only for severe symptoms that pose safety risks. 1

Assessment and Identification of Underlying Causes

A systematic approach to identifying precipitating factors is essential:

1. Search for common causes:

   • Dehydration and electrolyte imbalances
   • Infections (UTI, pneumonia, etc.)
   • Metabolic alterations
   • Medication adverse effects (especially anticholinergics, benzodiazepines)
   • Opioid neurotoxicity
   • Pain, hypoperfusion, high fever 2, 1

2. Targeted interventions based on identified causes:

   • Correct electrolyte abnormalities (e.g., magnesium replacement)
   • Treat infections appropriately
   • Consider opioid rotation to fentanyl or methadone if opioid neurotoxicity is present
   • Discontinue or modify deliriogenic medications 1

Non-Pharmacological Interventions

Non-pharmacological approaches should be implemented for all patients with delirium:

• Reorientation strategies: clocks, calendars, familiar objects
• Ensure proper hydration and nutrition
• Sleep hygiene: maintain day-night cycle, reduce nighttime disruptions
• Early mobilization when medically stable
• Cognitive stimulation during the day
• Family involvement: provide information about delirium and encourage presence
• Avoid physical restraints when possible 2, 1

Pharmacological Management

Medications should be used only when non-pharmacological approaches are insufficient:

For Hyperactive or Mixed Delirium with Agitation:

1. First-line options:

   • Atypical antipsychotics: olanzapine (5-10mg IM), quetiapine, or aripiprazole 1
   • These have fewer anticholinergic effects and lower risk of extrapyramidal symptoms

2. Alternative options:

   • Haloperidol: 2-5mg IV/IM for severe agitation (traditional first-line agent)
   • Monitor for QTc prolongation and extrapyramidal symptoms 1, 3

3. For severe agitation unresponsive to antipsychotics:

   • Lorazepam: 1-2mg IV/IM (benzodiazepine of choice due to rapid onset, shorter duration, and low risk of accumulation) 1, 3
   • Note: Benzodiazepines should be used with caution as they may worsen delirium except in alcohol/sedative withdrawal delirium 3

For Hypoactive Delirium:

• Methylphenidate may be considered to improve cognition when no delusions or perceptual disturbances are present 1
• Dexmedetomidine has shown promise in mechanically ventilated patients 2

Special Considerations

1. ICU Delirium:

   • Implementation of the ABCDEF Bundle has been associated with reduced delirium and ventilation time 2
   • Prefer short-acting sedatives (propofol, dexmedetomidine) over benzodiazepines 2

2. Elderly Patients:

   • Start medications at lower doses
   • Monitor more frequently for adverse effects
   • Higher risk of complications from both delirium and medications 1

3. Opioid-Associated Delirium:

   • Consider opioid rotation rather than antipsychotics 1

4. Terminal Delirium:

   • Focus on symptom control and comfort 1

5. Parkinson's Disease/Lewy Body Dementia:

   • Avoid typical antipsychotics; consider quetiapine if medication is necessary 1

Monitoring and Follow-up

• Assess delirium symptoms at least daily using validated tools (CAM-ICU or ICDSC) 2
• Discontinue medications as soon as possible when symptoms resolve
• Continue non-pharmacological interventions throughout hospitalization
• Monitor for medication side effects, especially QTc prolongation with antipsychotics 1

Common Pitfalls to Avoid

1. Overlooking hypoactive delirium - less obvious but equally serious
2. Excessive sedation - may prolong or worsen delirium
3. Inappropriate use of physical restraints - can increase agitation and worsen outcomes
4. Failing to address underlying causes - treating symptoms without addressing etiology
5. Prolonged use of antipsychotics - limited evidence for efficacy and potential for harm 1, 4

Remember that prevention is more effective than treatment, and multicomponent non-pharmacological approaches have the strongest evidence base for both prevention and management of delirium 4.