What is the initial management of delirium?

Initial Management of Delirium

The initial management of delirium should focus on identifying and treating underlying causes while implementing non-pharmacological interventions before considering medication, as delirium is considered a medical emergency requiring prompt intervention to reduce mortality. 1, 2

Assessment and Diagnosis

• Use validated screening tools such as the Confusion Assessment Method (CAM), CAM-ICU, or ICDSC for early detection and monitoring of delirium 1, 2
• Perform clinical assessment within 24 hours to identify potential contributing factors 2
• Monitor patients daily for changes in cognitive function, behavior, or physical status that may indicate delirium 1
• Recognize that delirium often goes undetected without standardized screening tools, with bedside nurses and physicians frequently missing cases 1

Identifying and Treating Underlying Causes

• Infection is the most common precipitating factor, particularly urinary tract infections and pneumonia 1

• Investigate for other common causes including:

  • Medications (especially anticholinergics, benzodiazepines, opioids, and steroids) 2, 3
  • Metabolic or endocrine disturbances 1
  • Pain, dehydration, and constipation 2
  • Neurological processes (traumatic brain injury, cerebrovascular disease) 1
  • Organ dysfunction 1
  • Drug/alcohol intoxication or withdrawal 1

• Address all identified causes promptly - 20-50% of delirium episodes can be reversed in patients who are not imminently dying 1

Non-Pharmacological Interventions (First-Line)

• Maintain continuity of care with familiar healthcare professionals 2
• Provide appropriate environmental modifications:
  • Ensure proper lighting and clear signage 2
  • Make clocks and calendars easily visible 2
  • Avoid unnecessary room transfers 2
• Reorient the patient regularly through conversation 2
• Ensure adequate hydration 2
• Implement sleep hygiene measures to promote normal sleep-wake cycles 2
• Facilitate regular visits from family members 2, 4
• Encourage early mobility when possible 5

Pharmacological Management (Second-Line)

• Limit pharmacological interventions to patients with distressing symptoms (such as hallucinations or delusions) or when there are safety concerns 1, 2
• For moderate delirium requiring medication, consider:
  • Olanzapine 1, 2
  • Quetiapine 1, 2
  • Aripiprazole 1, 2
• Avoid haloperidol and risperidone as first-line agents as they have not demonstrated benefit in mild-to-moderate delirium and may worsen symptoms 2
• Use medications at the lowest effective dose and for the shortest duration possible 1
• Consider methylphenidate for hypoactive delirium without delusions or perceptual disturbances 1
• Reserve benzodiazepines for:
  • Crisis intervention in severely agitated patients 1
  • First-line treatment in alcohol or benzodiazepine withdrawal 1, 6

Family and Staff Support

• Provide written information about delirium to family members 2
• Offer educational and psychological support for families 2
• Conduct formal debriefing sessions for healthcare team members after challenging cases 1
• Provide debriefing opportunities for patients who recover from delirium 1

Common Pitfalls to Avoid

• Failing to recognize hypoactive delirium, which is often underdiagnosed but is the most prevalent subtype in palliative care patients 3
• Using benzodiazepines as initial treatment (except in alcohol/benzodiazepine withdrawal) as they can worsen delirium 3, 4
• Overlooking the contribution of multiple medications simultaneously to delirium 3
• Delaying treatment of underlying causes, which can increase mortality 1
• Missing delirium due to lack of systematic screening 1

Monitoring and Follow-up

• Regularly reassess mental status using standardized tools 2
• Adjust treatment approaches based on symptom control and patient distress 2
• Monitor for medication side effects, particularly extrapyramidal symptoms with antipsychotics 1