What is the treatment approach for delirium?

Treatment Approach for Delirium

The most effective treatment for delirium involves a multicomponent, nonpharmacologic intervention focused on identifying and addressing underlying causes, while pharmacologic treatments should be reserved for specific situations where symptom management is necessary. 1

Comprehensive Assessment and Identification of Causes

• For patients with delirium, identify predisposing and precipitating factors through a comprehensive initial assessment 1
• Target high-risk groups for intervention, including persons aged 65 years or older, those with cognitive impairment or dementia, severe illness, and current hip fracture 1
• Address potentially reversible causes of delirium:
  • Treat infections if consistent with patient's goals of care 1
  • Manage hypercalcemia with bisphosphonates (IV pamidronate, zoledronic acid) 1
  • Correct hypomagnesemia with magnesium replacement 1
  • Discontinue medications that may be contributing to delirium 1
  • Consider opioid rotation if signs of opioid-induced neurotoxicity are present 1

Nonpharmacologic Interventions

• Implement multicomponent interventions that include:

  • Reorientation strategies (clocks, calendars, cognitive stimulation) 1
  • Sleep improvement measures (minimizing light and noise) 1
  • Early mobilization and rehabilitation 1
  • Ensuring proper use of hearing aids and eyeglasses 1
  • Maintaining adequate nutrition and hydration 1
  • Minimizing unnecessary patient transfers within the hospital 1
  • Infection control measures 1
  • Pain management 1

• Provide educational and psychological support for families, including written information about delirium 1

Pharmacologic Management

• Do not routinely use antipsychotics (haloperidol or atypical antipsychotics) or statins to treat delirium 1

• Consider short-term use of antipsychotics only for patients experiencing:

  • Significant distress from hallucinations or delusions 1
  • Agitation that may cause physical harm to themselves or others 1
  • Discontinue immediately following resolution of distressing symptoms 1

• For mechanically ventilated patients with agitation precluding weaning/extubation, consider dexmedetomidine 1

• For specific delirium subtypes:

  • In alcohol or sedative-hypnotic withdrawal delirium, benzodiazepines are the treatment of choice 2
  • Lorazepam is preferred among benzodiazepines due to its rapid onset, shorter duration, low risk of accumulation, and predictable bioavailability 2

Special Considerations

• For cancer patients:

  • Olanzapine, quetiapine, or aripiprazole may offer benefit in symptomatic management of delirium 1
  • Methylphenidate may improve cognition in hypoactive delirium without delusions or perceptual disturbances 1
  • Benzodiazepines can provide sedation and anxiolysis in severe symptomatic distress associated with delirium 1

• For ICU patients:

  • Implement the ABCDEF bundle (Assessment of pain, Both spontaneous awakening and breathing trials, Choice of sedation, Delirium monitoring/management, Early mobility, Family engagement) 1
  • Monitor for non-convulsive status epilepticus in high-risk patients, as it can present as delirium 1

Implementation Considerations

• Ensure high fidelity in implementing multicomponent interventions—all components should be provided to all at-risk patients consistently 1
• Provide interprofessional delirium education as a core component of hospital-wide strategy 1
• Recognize that about one-third of delirium cases can be prevented through risk factor modification 1
• Treat delirium as an acute neurologic emergency requiring prompt intervention 3