What is the initial workup and management for a patient with delirium?

Initial Workup and Management for Delirium

The initial workup for delirium should focus on identifying and treating the underlying causes through a comprehensive assessment of predisposing and precipitating factors, while implementing non-pharmacological interventions as first-line management before considering pharmacological options. 1

Diagnosis and Assessment

Clinical Evaluation

• Diagnose delirium using DSM or ICD criteria by a trained healthcare professional 2
• Look for cardinal features:
  • Acute onset (hours to days) and fluctuating course
  • Disturbed level of consciousness
  • Change in cognition (disorientation, memory impairment)
  • Perceptual disturbances 1
• Identify delirium subtype: hyperactive, hypoactive, or mixed 1
  • Hypoactive delirium is often underdiagnosed but is the most prevalent subtype in palliative care 2

Initial Workup

1. Laboratory investigations:

   • Complete blood count
   • Comprehensive metabolic panel (electrolytes, BUN, creatinine)
   • Calcium, magnesium levels
   • Glucose
   • Thyroid function tests
   • Urinalysis
   • Blood cultures if infection suspected 2

2. Imaging and additional tests (as indicated):

   • Chest X-ray
   • CT or MRI of brain if neurological causes suspected
   • EEG if seizure activity suspected
   • Lumbar puncture if CNS infection suspected 2, 1

3. Medication review:

   • Identify and discontinue delirium-inducing medications (steroids, anticholinergics) 2
   • Review opioids for potential neurotoxicity 2

Management Approach

Non-Pharmacological Interventions (First-Line)

• Environmental modifications:

  • Ensure adequate lighting during day, reduce at night
  • Minimize noise and patient transfers
  • Place familiar objects, calendars, and clocks for orientation 1

• Cognitive support:

  • Frequent reorientation
  • Cognitive stimulation through appropriate activities
  • Clear communication 1

• Sensory optimization:

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

• Early mobilization:

  • Avoid unnecessary bed rest and physical restraints
  • Assist with ambulation at least three times daily when possible 1

• Sleep-wake cycle regulation:

  • Increase daylight exposure during waking hours
  • Reduce noise and light during nighttime
  • Avoid daytime napping 1

Pharmacological Management (Second-Line)

1. For moderate delirium symptoms:

   • Oral haloperidol, risperidone, olanzapine, or quetiapine 2
   • Note: Recent evidence suggests haloperidol or risperidone may not be beneficial for mild-to-moderate delirium 2

2. For severe delirium with agitation:

   • Antipsychotic medications: haloperidol, olanzapine, or chlorpromazine 2
   • Intravenous chlorpromazine only for bed-bound patients due to hypotensive effects 2

3. For refractory agitation:

   • Add benzodiazepine (lorazepam) only after establishing therapeutic levels of neuroleptics 2
   • Avoid benzodiazepines as initial treatment for patients not already taking them 2

4. For opioid-induced delirium:

   • Consider opioid rotation (switching to fentanyl or methadone) 2
   • Reduce opioid dose if appropriate 2

Special Considerations

Reversibility

• 20-50% of delirium episodes can be reversed in patients with advanced cancer who are not imminently dying 2
• Medication-induced delirium is usually reversible, while delirium due to hypoxic encephalopathy or organ failure is often irreversible 2

Refractory Delirium in End-of-Life Care

• If delirium is due to disease progression in dying patients:
  • Focus on symptom management and family support
  • Adjust neuroleptic and benzodiazepine doses or routes of administration
  • Remove unnecessary medications and tubes 2
  • Consider palliative sedation for refractory delirium after specialist consultation 2

Patient and Family Support

• Provide education about delirium to family members
• Explain the fluctuating nature of symptoms
• Support caregivers in coping with this distressing condition 2, 1

Common Pitfalls to Avoid

• Failing to recognize hypoactive delirium (more common but less obvious than hyperactive delirium)
• Missing fluctuating symptoms with single assessments (perform multiple evaluations)
• Using benzodiazepines as first-line treatment (can worsen delirium)
• Overlooking non-pharmacological interventions before medication
• Inadequate collection of collateral history to establish baseline cognitive function 1

Remember that delirium is associated with increased mortality, longer hospital stays, and significant distress to patients and families, making prompt recognition and appropriate management essential for improving outcomes 1.