What are the criteria and management for delirium?

Criteria and Management for Delirium

Delirium is defined as an acute, fluctuating syndrome of altered attention, awareness, and cognition that requires prompt diagnosis and management using standardized criteria and evidence-based interventions.

Diagnostic Criteria for Delirium

Core Features (DSM-5 Criteria)

• Disturbance in attention and awareness (reduced ability to focus, sustain, or shift attention) 1
• Acute onset and fluctuating course (develops over hours to days with symptoms that vary in severity throughout the day, often worsening in the evening) 1
• Cognitive disturbance (memory deficit, disorientation, language disturbance) or perceptual disturbance (hallucinations, delusions) 1
• Not better explained by a pre-existing neurocognitive disorder or severely reduced level of arousal such as coma 1
• Evidence from history, examination, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication/withdrawal, or medication side effect 1

Clinical Presentations

• Hyperactive delirium: increased psychomotor activity, agitation, restlessness, increased speech, enhanced startle reaction 1
• Hypoactive delirium: reduced psychomotor activity, lethargy, decreased speech (often missed or misdiagnosed) 1
• Mixed delirium: fluctuating features of both hyperactive and hypoactive subtypes 1

Validated Assessment Tools

• Confusion Assessment Method (CAM): Most widely used diagnostic instrument with sensitivity of 82% and specificity of 99% 1
• CAM diagnostic algorithm requires: (1) acute onset and fluctuating course, (2) inattention, and either (3) disorganized thinking or (4) altered level of consciousness 1
• Other tools: Short Orientation Memory Concentration Test (SOMCT), reciting months of the year backwards (MOTYB) 1

Management of Delirium

Prevention Strategies (Non-pharmacological)

• Cognitive impairment interventions: Regular reorientation by staff and family, use of orientation boards and visible clocks, cognitive stimulation activities, avoiding frequent room changes 1
• Sensory impairment management: Ensure use of eyeglasses, hearing aids, and removal of impacted ear wax 1
• Mobility promotion: Encourage active range-of-motion exercises, early mobilization as allowed by patient's condition, avoid unnecessary urinary catheterization and physical restraints 1
• Hydration and nutrition: Encourage adequate fluid intake (if swallowing is safe), assist with meals when necessary 1
• Sleep-wake cycle regulation: Increase daylight exposure, discourage daytime napping, provide warm non-caffeinated drinks at bedtime, minimize nighttime noise and disruptions 1

Pharmacological Management

• First identify and treat underlying causes: Infection, metabolic disorders, medication side effects, pain, withdrawal 1
• Antipsychotics: Reserve for severe agitation that poses risk to patient/staff safety or threatens essential medical therapies 1, 2
  • Haloperidol is considered first-line treatment due to multiple administration routes, fewer active metabolites, limited anticholinergic effects 3
  • Monitor for effectiveness in reducing distress and delirium symptoms 1
  • Monitor for adverse effects including extrapyramidal symptoms and QTc prolongation 1
  • Avoid antipsychotics or use with extreme caution in patients with Parkinson's disease or Lewy body dementia 1, 4
• Benzodiazepines: Only recommended for alcohol or sedative withdrawal-related delirium, or when delirium is not controlled with antipsychotics 1, 3

Special Considerations

High-Risk Populations

• Elderly patients (>65 years) 1, 5
• Patients with pre-existing cognitive impairment or dementia 1, 5
• Cancer patients (prevalence up to 80% in advanced disease) 1
• Critically ill patients in ICU settings (up to 80% of mechanically ventilated patients) 1
• Postoperative patients 1, 2

Common Pitfalls in Delirium Management

• Failure to recognize hypoactive delirium (often mistaken for depression or fatigue) 1
• Misdiagnosis as another psychiatric disorder (occurs in up to 37% of cancer patients) 1
• Overlooking delirium superimposed on dementia in older patients 1
• Inadequate assessment of medication effects, particularly in polypharmacy situations 5, 4
• Relying solely on pharmacological interventions without addressing modifiable environmental factors 1, 2

Monitoring and Follow-up

• Regularly reassess using validated tools to monitor response to interventions 1, 2
• Continue monitoring for withdrawal symptoms after discontinuation of sedatives or opioids (if used >5 days) 1
• Ensure proper communication with family and caregivers about delirium symptoms and management 1, 5

Delirium increases risk of functional decline, institutionalization, and mortality, making prompt recognition and appropriate management essential for improving outcomes 5, 2.