What is the general overview of hospital delirium treatment?

Hospital Delirium Treatment and Workup: General Overview

The cornerstone of hospital delirium management is implementing multicomponent nonpharmacologic interventions while simultaneously identifying and treating reversible precipitating factors; antipsychotics should NOT be routinely used and have been shown to worsen outcomes in mild-to-moderate delirium. 1, 2

Initial Assessment and Risk Stratification

Identify high-risk patients immediately upon admission:

• Age ≥65 years 1, 2
• Pre-existing cognitive impairment or dementia 1, 2
• Severe acute illness 1, 2
• Hip fracture patients 1, 2

Use validated screening tools for detection:

• Confusion Assessment Method-ICU (CAM-ICU) - takes <2 minutes, focuses on inattention as core feature 1
• Intensive Care Delirium Screening Checklist (ICDSC) - 8-domain assessment over current and prior shift 1
• Modified Richmond Agitation and Sedation Scale for monitoring mental status changes 3

Comprehensive Workup to Identify Reversible Causes

Systematically evaluate and address these precipitating factors:

Medication Review (Priority #1)

• Discontinue or reduce benzodiazepines - strongest modifiable risk factor 1
• Review and stop anticholinergic medications 2
• Assess for opioid-induced delirium - consider rotation to fentanyl or methadone with 30-50% dose reduction 1
• Eliminate other psychoactive medications 2

Metabolic and Physiological Derangements

• Treat infections promptly 1, 2
• Correct hypoxia and optimize oxygenation 1, 2
• Address hypercalcemia with bisphosphonates 2
• Correct hypomagnesemia with magnesium replacement 2
• Ensure adequate hydration and nutrition 1, 2

Environmental and Iatrogenic Factors

• Minimize unnecessary patient transfers between units 1, 2
• Assess for uncontrolled pain 1, 2
• Evaluate sleep disruption from noise and nighttime interruptions 1

Multicomponent Nonpharmacologic Interventions (The Foundation)

These interventions prevent approximately one-third of delirium cases and should be implemented with high fidelity for ALL at-risk patients: 1

Cognitive and Orientation Strategies

• Regular reorientation to person, place, time 1, 2
• Provide visible clocks and calendars 4
• Ensure adequate lighting and clear signage 4
• Maintain care team consistency 4

Sensory Optimization

• Ensure hearing aids are in place and functioning 1, 2
• Provide eyeglasses for vision correction 1, 2

Mobility and Physical Function

• Early mobilization and walking programs 1, 2
• Physical rehabilitation as tolerated 1, 2

Sleep Hygiene

• Reduce nighttime noise and interruptions 1, 4
• Maintain normal day-night cycles 4
• Use nonpharmacologic sleep promotion strategies 1

Nutrition and Hydration

• Maintain adequate oral intake 1, 2
• Address dehydration promptly 4

Pain Management

• Optimize pain control preferably with nonopioid medications 4
• Consider regional anesthesia for surgical patients 4

Family Involvement

• Provide written educational materials about delirium 1, 4
• Incorporate family into reorientation and care when possible 5

ICU-Specific Approach: ABCDEF Bundle

For critically ill patients, implement this evidence-based bundle associated with reduced delirium duration and improved survival: 1, 2

• Assess, prevent, and manage pain
• Both spontaneous awakening and breathing trials
• Choice of analgesia and sedation
• Delirium assessment, prevention, and management
• Early mobility and exercise
• Family engagement and empowerment

Pharmacologic Management: When and What to Use

What NOT to Use (Critical)

Haloperidol and risperidone are NOT recommended for mild-to-moderate delirium and have been shown to worsen symptoms compared to placebo in cancer patients. 1

Do NOT routinely use antipsychotics or statins to treat delirium. 2

Avoid antipsychotics and benzodiazepines for hypoactive delirium. 4

Limited Indications for Pharmacologic Treatment

Consider antipsychotics ONLY for:

• Severe distress from hallucinations or delusions 2
• Agitation causing imminent physical harm to self or others 2, 4
• Use lowest effective dose for shortest duration 4
• Discontinue immediately when distressing symptoms resolve 2

Medication Options (When Indicated)

For hyperactive/agitated delirium requiring medication:

• Olanzapine - may offer benefit, causes sedation which can be advantageous 1
• Quetiapine - may offer benefit, sedating, oral only 1
• Aripiprazole - may offer benefit, available in parenteral forms 1

For mechanically ventilated patients with agitation preventing weaning:

• Dexmedetomidine is preferred 2

For hypoactive delirium WITHOUT delusions or perceptual disturbances:

• Methylphenidate may improve cognition 1, 2

For alcohol or sedative withdrawal delirium:

• Benzodiazepines are drugs of choice (lorazepam preferred) 6

Implementation Considerations

The challenge is achieving high fidelity - doing ALL interventions ALL the time for ALL at-risk patients, not just some interventions some of the time. 1

This requires:

• Interprofessional delirium education as core hospital strategy 2
• System-level support for reliable delivery of specific tasks 1
• Standardized protocols embedded in routine care 3

Special Populations

ICU patients:

• Monitor for non-convulsive status epilepticus in high-risk patients 2
• Recognize that hypoactive delirium is more common and carries worse prognosis 1

Cancer patients:

• Address reversible causes aggressively (infections, hypercalcemia, medications) 1, 2
• Consider second-generation antipsychotics if pharmacologic management needed 1

Economic and Outcome Impact

Delirium prevention is cost-effective, reducing both costs and improving health outcomes compared to usual care. 1, 4

Every day with delirium increases mortality hazard by 10% and is associated with:

• Longer mechanical ventilation and ICU stays 1
• Persistent cognitive decline for months to years 1
• Increased 30-day costs of $22,000 per patient 1
• Annual U.S. healthcare costs of $143-152 billion 1

Critical Pitfalls to Avoid

Do not reflexively prescribe antipsychotics - recent high-quality RCTs show no benefit and potential harm in mild-to-moderate delirium 1

Do not miss hypoactive delirium - it is more common than hyperactive delirium and carries worse outcomes 1, 3

Do not overlook benzodiazepines - they are the most important modifiable pharmacologic risk factor 1

Do not implement interventions sporadically - prevention requires consistent, comprehensive application of all components 1

Do not forget that delirium is a medical emergency requiring immediate identification and treatment of underlying causes 7