What is the treatment course for delirium?

Treatment Course for Delirium

The treatment of delirium should focus on identifying and managing underlying causes through a comprehensive initial assessment, implementing multicomponent nonpharmacologic interventions, and using pharmacologic treatments only when necessary for severe symptoms. 1

Diagnosis and Assessment

• Delirium diagnosis should be made by a trained healthcare professional using clinical assessment based on DSM or ICD criteria, characterized by disturbances in attention, awareness, and cognition developing over a short period 1
• Changes in cognitive or emotional behavior or psychomotor activity suggestive of delirium warrant clinical assessment to confirm diagnosis 1
• Delirium typically presents as hyperactive (agitated), hypoactive (lethargic), or mixed subtypes, with hypoactive being most common in palliative care patients and often underdiagnosed 2

Management of Underlying Causes

• Identify predisposing and precipitating factors through comprehensive initial assessment 1

• Common causes include:

  • Infections (should be treated if aligned with patient's goals of care) 1
  • Metabolic disturbances (hypercalcemia, hypomagnesemia, SIADH) 1
  • Medication side effects (particularly opioids, anticholinergics, steroids) 1, 2
  • Organ failure, hypoxia, or dehydration 1

• Specific interventions for identified causes:

  • Opioid rotation to fentanyl or methadone with 30-50% dose reduction if opioid-induced neurotoxicity is present 1, 2
  • Bisphosphonates (IV pamidronate, zoledronic acid) for hypercalcemia 1
  • Magnesium replacement for hypomagnesemia 1
  • Discontinuation of implicated medications, fluid restriction, and adequate oral salt intake for SIADH 1

Non-pharmacological Interventions

• Multicomponent nonpharmacologic interventions delivered by an interdisciplinary team should be first-line treatment 1, 2
• Implement reorientation strategies, cognitive stimulation, and sleep hygiene measures 2
• Create a calm environment that promotes orientation and prevents falls 2
• Ensure open communication with patients and family members to reduce distress 2
• Optimize pain management, preferably with nonopioid medications 1
• Avoid medications with high risk for precipitating delirium 1
• Ongoing educational programs regarding delirium should be provided for healthcare professionals 1

Pharmacological Management

• Medications should be used only when non-pharmacological approaches have failed and for severe symptoms causing distress 1, 2
• Avoid haloperidol and risperidone as they have no demonstrable benefit in mild-to-moderate delirium and may worsen symptoms 1
• For moderate delirium symptoms requiring medication:
  • Olanzapine may offer benefit in symptomatic management 1, 3
  • Quetiapine may be effective and better tolerated in medically ill patients 1, 4
  • Aripiprazole may offer benefit with fewer adverse events 1
• For hypoactive delirium without delusions or perceptual disturbances, methylphenidate may improve cognition 1
• Benzodiazepines should not be used as first-line treatment of agitation associated with delirium 1, 2
• Cholinesterase inhibitors should not be newly prescribed to prevent or treat delirium 1

Special Considerations

• For refractory delirium in dying patients, focus on symptom management and family support 2
• Antipsychotics and benzodiazepines should be avoided for hypoactive delirium 1
• Monitor response to interventions and adjust treatment approaches based on symptom control and patient distress 2
• Provide information about delirium to families to reduce distress and involve them in monitoring for changes 2
• Offer debriefing opportunities for patients who recover from delirium episodes 2

Common Pitfalls to Avoid

• Failing to recognize hypoactive delirium due to its less obvious presentation 2
• Using antipsychotics as first-line treatment before addressing underlying causes 1
• Overlooking the importance of non-pharmacological interventions 1, 2
• Using benzodiazepines as first-line treatment, which can worsen delirium 1, 5
• Not involving family members in care and education about delirium 2