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

Initial Workup and Management for a Patient with Delirium

The initial workup for a patient with delirium should focus on identifying and addressing underlying causes through a comprehensive assessment, while implementing non-pharmacological interventions as first-line management and using pharmacological treatments only when necessary for patient safety or severe distress. 1, 2

Diagnosis and Assessment

• Diagnosis should be made by a trained healthcare professional using clinical assessment based on DSM or ICD criteria 1
• Within 24 hours of hospitalization, assess the patient for clinical factors contributing to delirium 1
• Use standardized tools like the Confusion Assessment Method (CAM) or CAM-ICU for detection and monitoring 2, 3
• Consider EEG evaluation to differentiate hypoactive delirium from non-convulsive status epilepticus in patients with persistent consciousness disorders 2

Identifying Underlying Causes

• Search for and address reversible causes of delirium, including:
  • Medications (particularly anticholinergics, steroids, opioids) 2
  • Infections (urinary tract, respiratory) 4
  • Metabolic disturbances 4
  • Pain 1
  • Dehydration and constipation 1
  • Hypoxia 4

Non-Pharmacological Management (First-Line)

• Ensure continuity of care by having the patient cared for by a familiar team of healthcare professionals 1
• Avoid moving patients between rooms or wards unless absolutely necessary 1
• Address cognitive impairment or disorientation by:
  • Providing appropriate lighting and clear signage 1
  • Ensuring a clock and calendar are easily visible 1
  • Talking to the patient to reorient them by explaining where they are, who they are, and what your role is 1
  • Introducing cognitively stimulating activities 1
  • Facilitating regular visits from family and friends 1
• Address dehydration by ensuring adequate fluid intake 1
• Implement sleep hygiene measures to promote normal sleep-wake cycles 2

Pharmacological Management

• Pharmacological interventions should be limited to patients who have distressing delirium symptoms or if there are safety concerns 1
• Avoid haloperidol and risperidone as they have not demonstrated benefit in mild-to-moderate delirium and may worsen symptoms 1, 2
• For moderate delirium symptoms requiring medication, consider:
  • Olanzapine (starting dose: 2.5-5 mg orally) 1
  • Quetiapine (oral formulations only) 1
  • Aripiprazole (5 mg orally or IM) 1
• For severe agitation requiring immediate intervention:
  • Benzodiazepines (e.g., midazolam 2.5 mg SC/IV or lorazepam 1 mg SC/IV) may be used as crisis medication, but only for severe symptomatic distress 1
  • Benzodiazepines are first-line agents only for alcohol or benzodiazepine withdrawal 1
• Use medications in the lowest effective dose and for the shortest period of time possible 1

Family and Staff Support

• Provide written information about delirium to family members in the form of a leaflet/brochure 1
• Include in the information:
  • Definition of delirium, specifying causes, symptoms, evolution and management 1
  • Explanation of the fluctuating nature of delirium 1
  • Guidance on appropriate responses and non-pharmacological interventions 1
• Supplement written information with educational and psychological support for families 1
• Offer debriefing opportunities for patients who recover from delirium episodes 1
• Provide interprofessional delirium education for the healthcare team 1

Monitoring and Follow-up

• Regularly reassess the patient's mental status using standardized tools 2
• Adjust treatment approaches based on symptom control and patient distress 2
• Continue to address underlying causes as they are identified 2

Special Considerations

• Hypoactive delirium is often underdiagnosed due to its less obvious presentation 2
• For delirium in patients with advanced disease and limited life expectancy, focus on symptom management and family support 2
• For refractory delirium in dying patients, consider palliative sedation after specialist consultation 2