What are the guidelines for managing delirium?

Guidelines for Managing Delirium

Multicomponent nonpharmacologic interventions delivered by an interdisciplinary team should be the foundation of delirium prevention and management in at-risk patients. 1

Identification and Risk Assessment

• 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 2
• Use standardized tools like the Confusion Assessment Method (CAM) or CAM-ICU for detection and monitoring of delirium 3
• Perform a comprehensive medical evaluation to identify and manage underlying contributors to delirium 1

Prevention Strategies

Multicomponent Nonpharmacologic Interventions

• Address cognitive impairment/disorientation through:

  • Regular reorientation of the patient 3
  • Ensuring adequate lighting and clear signage 3
  • Providing visible clock and calendar 3
  • Minimizing room changes and maintaining care team consistency 1

• Manage physical factors:

  • Ensure adequate hydration and nutrition 1
  • Address hypoxia and optimize oxygenation 1
  • Treat infections promptly 2
  • Promote early mobilization and rehabilitation 2
  • Ensure proper use of hearing aids and eyeglasses 2
  • Manage pain effectively, preferably with nonopioid medications 1
  • Address constipation, urinary retention, and dehydration 1

• Implement sleep hygiene measures:

  • Reduce noise and interruptions during sleep hours 2
  • Maintain normal day-night cycles 3

Healthcare Professional Education

• Provide ongoing educational programs regarding delirium for healthcare professionals 1
• Ensure high fidelity in implementing multicomponent interventions 1

Management of Established Delirium

Nonpharmacologic Approaches

• Continue multicomponent nonpharmacologic interventions when delirium is diagnosed 1
• Provide educational and psychological support for families, including written information about delirium 2, 3
• Facilitate regular visits from family and friends 3

Pharmacologic Management

• Medications with high risk for precipitating delirium should be avoided 1
• Cholinesterase inhibitors should not be newly prescribed to prevent or treat delirium 1
• Benzodiazepines should not be used as first-line treatment of agitation associated with delirium 1
• Antipsychotics and benzodiazepines should be avoided for treatment of hypoactive delirium 1
• For severely agitated or distressed patients, or those threatening substantial harm to self/others, consider antipsychotics (haloperidol, risperidone, olanzapine, quetiapine, or ziprasidone) at the lowest effective dose for the shortest possible duration 1
• For mechanically ventilated patients with agitation precluding weaning/extubation, consider dexmedetomidine 2

Special Considerations

Pain Management

• Optimize pain management, preferably with nonopioid medications 1
• Consider regional anesthetic at the time of surgery and postoperatively to improve pain control 1

Monitoring and Follow-up

• Regularly reassess mental status using standardized tools 3
• Monitor for medication side effects, particularly extrapyramidal symptoms with antipsychotics 3
• Adjust treatment approaches based on symptom control and patient distress 3

Common Pitfalls to Avoid

• Failing to recognize delirium, particularly hypoactive forms 4
• Using antipsychotics as first-line treatment when nonpharmacologic approaches would suffice 1
• Prescribing benzodiazepines for agitation (except in alcohol withdrawal) 1
• Neglecting to identify and treat underlying causes 2
• Failing to implement multicomponent interventions with high fidelity 1
• Not providing adequate family education and support 2, 3

Economic Impact

• About one-third of delirium cases can be prevented through risk factor modification 1
• Delirium prevention is a cost-effective strategy that reduces cost and improves health outcomes compared with usual care 1