What is the initial management of a patient presenting with delirium?

Initial Management of Delirium

The initial management of a patient presenting with delirium should focus on identifying and treating the underlying causes through a comprehensive assessment, with particular attention to medication review, infection, metabolic abnormalities, and neurologic causes. 1

Diagnosis and Assessment

• Delirium diagnosis should be made using validated tools such as the Confusion Assessment Method (CAM) to objectively identify the condition 2
• Distinguish delirium from dementia by assessing onset (acute vs. gradual), course (fluctuating vs. stable), attention (impaired vs. relatively preserved), and level of consciousness (altered vs. clear) 1
• Evaluate for recent changes in cognitive function, behavior, or physical function, including impaired concentration, slow responses, withdrawal, sleep disturbances, hallucinations, confusion, agitation, or mood changes 1

Initial Workup

• Complete blood count to assess for infection 1, 2
• Comprehensive metabolic panel to evaluate electrolytes, renal function, liver function 1, 2
• Urinalysis to rule out urinary tract infection 1, 2
• Blood glucose measurement 1, 2
• Medication levels when appropriate (e.g., digoxin, anticonvulsants) 1
• Consider blood cultures if infection is suspected 1
• Evaluate for hypercalcemia, hypomagnesemia, and SIADH as these are common metabolic causes 1
• Electrocardiogram to assess for myocardial ischemia or arrhythmias 2
• Chest radiography to evaluate for pneumonia or other pulmonary processes 2
• Selective neuroimaging guided by specific clinical features (focal neurological deficits, recent head trauma, new onset seizures, signs of increased intracranial pressure) 2

Evaluation of Common Precipitating Factors

• Review all medications with special attention to vasodilators, diuretics, antipsychotics, sedative/hypnotics, and anticholinergics 1
• Consider opioid-induced neurotoxicity, especially in cancer patients - opioid rotation with dose reduction of 30-50% may be beneficial 3
• Evaluate for common infections including urinary tract infection, pneumonia, and sepsis 1, 3
• Assess for electrolyte disturbances, hypoglycemia or hyperglycemia, acid-base disorders, and renal or hepatic dysfunction 1

Non-pharmacological Management

• Maintain normal sleep-wake cycles 1, 4
• Provide appropriate sensory aids (glasses, hearing aids) 1
• Create a calm, well-lit environment 1, 4
• Reorientation strategies and cognitive stimulation 3
• Reduce or eliminate delirium-inducing medications (steroids, anticholinergics) 3
• Consider clinically assisted hydration if dehydration is determined to be a potential precipitating factor 3

Pharmacological Management

• Pharmacological interventions should be limited to patients with distressing symptoms (perceptual disturbances) or safety concerns 3, 1
• Medications should be used at the lowest effective dose and for the shortest time possible 3, 1

First-line options for moderate to severe symptomatic delirium:

• Haloperidol: 0.5-1 mg PO or SC, with PRN dosing of 0.5 or 1 mg q1h (use lower doses in older or frail patients) 3
• Olanzapine: 2.5-5 mg PO or SC (appears less likely to cause extrapyramidal side effects than first-generation antipsychotics) 3
• Quetiapine: May offer benefit in the symptomatic management of delirium 3

Special situations:

• For hypoactive delirium without delusions or perceptual disturbance: Consider methylphenidate 3
• For alcohol or benzodiazepine withdrawal delirium: Benzodiazepines are first-line agents 3
• For severe symptomatic distress: Benzodiazepines (lorazepam) may be added to antipsychotics for agitation refractory to high doses of neuroleptics 3

Family Support and Education

• Provide families with information about delirium pre-emptively and at repeated intervals, especially if the patient's condition is declining 3
• Supplement written information with educational and psychological support for families by suitably trained staff 3
• Explain that delirium is often distressing for patients and families but can potentially improve with appropriate management 3

Clinical Pitfalls to Avoid

• Mistaking delirium for dementia or psychiatric disorders 1
• Focusing on a single etiology when delirium is often multifactorial 1
• Failing to recognize hypoactive delirium 2
• Attributing symptoms to dementia without investigating for acute causes 2
• Inadequate screening leading to missed diagnosis in emergency settings 2