What is the approach to managing a patient with delirium?

Approach to Managing Delirium

The management of delirium requires a systematic approach that prioritizes identification of underlying causes, implementation of non-pharmacological interventions, and judicious use of pharmacological treatments when necessary. 1

Diagnosis and Assessment

• Diagnosis should be made by a trained healthcare professional using clinical assessment based on DSM or ICD criteria 1, 2
• If changes in cognitive or emotional behavior or psychomotor activity suggestive of delirium are present, a clinical assessment should be performed to confirm diagnosis 2
• Standardized tools like the Confusion Assessment Method (CAM) or CAM-ICU should be used for detection and monitoring 1, 3
• Up to 35% of non-ICU patients and 80% of ICU patients experience delirium, with elderly patients being particularly vulnerable 4

Identifying and Managing Underlying Causes

• Identify predisposing and precipitating factors through a comprehensive initial assessment 2
• Common reversible causes to address include:
  • Medications (particularly those with anticholinergic effects) 1, 4
  • Infections (treat if in accordance with patient's goals of care) 2
  • Metabolic disturbances:
    • Hypercalcemia (treat with bisphosphonates like IV pamidronate or zoledronic acid) 2
    • Hypomagnesemia (provide magnesium replacement) 2
    • SIADH (discontinue implicated medications, implement fluid restriction, ensure adequate oral salt intake) 2
  • Opioid-induced neurotoxicity (consider opioid rotation) 2, 5
  • Pain, hypoxia, urinary retention, constipation, dehydration 6

Non-Pharmacological Management

• Implement environmental interventions:
  • Ensure adequate lighting and clear signage 1, 6
  • Provide clock and calendar for orientation 1
  • Minimize room changes and maintain continuity of care with familiar staff 1
  • Create a calming environment with decreased sensory stimulation 6
• Address cognitive impairment:
  • Regularly reorient the patient 1, 6
  • Introduce cognitively stimulating activities 1
  • Facilitate regular visits from family and friends 1
• Ensure adequate hydration and nutrition 1, 6
• Implement sleep hygiene measures to promote normal sleep-wake cycles 1

Pharmacological Management

• Pharmacological interventions should be limited to patients with distressing symptoms or safety concerns 1, 5
• Avoid haloperidol and risperidone as first-line agents as they have not demonstrated benefit in mild-to-moderate delirium and may worsen symptoms 1
• For moderate delirium symptoms requiring medication, consider:
  • Olanzapine, quetiapine, or aripiprazole 1
  • For severe agitation, haloperidol 0.5-1 mg orally at night and every 2 hours when required may be used 6, 7
  • For anxiety-related agitation, lorazepam 0.25-0.5 mg orally four times a day as needed 6
• Use caution with benzodiazepines due to their potential to worsen delirium, except in cases of alcohol or drug withdrawal 4, 7
• Start with low doses of medications and keep treatment as short as possible 4

Family and Staff Support

• Provide written information about delirium to family members, including definition, causes, symptoms, evolution, and management 2, 1
• Offer guidance on appropriate responses and non-pharmacological interventions 2, 1
• Provide educational and psychological support for families 1
• Offer debriefing opportunities for patients who recover from delirium episodes 1

Monitoring and Follow-up

• Regularly reassess mental status using standardized tools 1, 6
• Monitor for medication side effects, particularly extrapyramidal symptoms with antipsychotics 6
• Adjust treatment approaches based on symptom control and patient distress 1

Special Considerations

• Hypoactive delirium is often underdiagnosed due to its less obvious presentation 1, 5
• For refractory delirium in actively dying patients, focus on symptom management and family support 2, 5
• In patients with underlying dementia, prioritize non-pharmacological approaches as first-line treatment 6

Common Pitfalls to Avoid

• Failing to identify and treat underlying medical causes 6
• Using high doses of medications in elderly patients without appropriate dose adjustments 6
• Neglecting non-pharmacological approaches before initiating medications 6
• Discharging patients with unresolved delirium symptoms 8