What is the assessment and plan (A/P) for delirium?

Assessment and Plan for Delirium

The management of delirium requires prompt identification of underlying causes through comprehensive assessment, followed by targeted treatment of precipitating factors, implementation of non-pharmacological interventions, and judicious use of medications only when necessary for patient safety. 1

Assessment

Diagnostic Approach

• Diagnosis should be made by a trained healthcare professional using clinical assessment based on DSM or ICD criteria 1, 2
• The Confusion Assessment Method (CAM) or its variants (CAM-ICU, B-CAM) should be used to objectively diagnose delirium 3, 4
• Delirium is characterized by acute onset, fluctuating course, inattention, and disorganized thinking 3, 4
• Distinguish delirium from dementia by assessing onset (acute vs. gradual), course (fluctuating vs. stable), and level of consciousness (altered vs. normal) 2

Initial Workup

• Identify predisposing and precipitating factors through comprehensive initial assessment 1, 2
• Laboratory testing should include complete blood count, comprehensive metabolic panel, urinalysis, blood glucose, and thyroid function tests 3, 5
• Evaluate for common infections including urinary tract infection and pneumonia, as infection is the most common precipitating factor 1, 5
• Review all medications with special attention to opioids, benzodiazepines, anticholinergics, and antidepressants 2, 6
• Consider neuroimaging selectively based on clinical features (focal deficits, recent trauma, unexplained altered mental status) 3, 2
• Assess for metabolic disturbances including hypercalcemia, hypomagnesemia, and SIADH 1, 2

Plan

Treatment of Underlying Causes

• Treat infections if considered a precipitating factor and in accordance with patient's goals of care 1, 5
• Consider opioid rotation if signs of opioid-induced neurotoxicity are present 1
• Discontinue implicated medications, especially those with anticholinergic properties 1, 6
• Correct electrolyte abnormalities: bisphosphonates for hypercalcemia, magnesium replacement for hypomagnesemia 1
• For SIADH, implement fluid restriction and ensure adequate oral salt intake 1
• Withdraw medications or therapies that may be contributing to delirium 1

Non-Pharmacological Interventions

• Maintain normal sleep-wake cycles and provide appropriate sensory aids (glasses, hearing aids) 2, 4
• Create a calm, well-lit environment to minimize confusion 2, 7
• Implement multicomponent delirium prevention strategies, which can reduce incidence by 40% 4, 7
• Provide frequent reorientation and ensure presence of familiar objects/people 4, 8

Pharmacological Management

• Pharmacological interventions should be limited to patients with distressing symptoms or safety concerns 2, 4
• Evidence does not support routine use of haloperidol or risperidone for mild-to-moderate delirium 1, 4
• If medication is necessary, use the lowest effective dose for the shortest time possible 2, 4
• Benzodiazepines should be reserved for alcohol or benzodiazepine withdrawal delirium or for severe symptomatic distress 2, 6
• Any antipsychotic prescription should include an appropriate taper plan 4

Monitoring and Follow-up

• Perform delirium assessment and documentation every 8-12 hours (at least once per shift) 3
• Pay special attention to hypoactive delirium, which is commonly missed but is the most frequent clinical subtype 3, 7
• Ensure follow-up with primary care providers on discharge for ongoing cognitive assessment 4
• Implement interprofessional delirium education as part of a hospital-wide strategy to improve recognition and management 1

Important Pitfalls to Avoid

• Failing to recognize hypoactive delirium, which is easily missed 3, 7
• Attributing symptoms to dementia without investigating for acute causes 3, 2
• Focusing on a single etiology when delirium is often multifactorial 2, 5
• Overuse of pharmacological interventions before optimizing non-pharmacological approaches 2, 4