What should I do if a patient at a long-term care facility shows signs of delirium?

Management of Delirium in Long-Term Care Facilities

When a patient in a long-term care facility shows signs of delirium, immediately implement a multicomponent nonpharmacologic intervention protocol while simultaneously conducting a focused medical evaluation to identify and treat the underlying cause. 1, 2

Immediate Actions

Step 1: Confirm Delirium Using a Validated Tool

• Use the Confusion Assessment Method (CAM) to confirm delirium presence, which takes only 2-5 minutes and has the highest psychometric properties for detection 1, 2
• Look for the cardinal features: acute onset with fluctuating course, inattention, and either disorganized thinking or altered level of consciousness 1
• Critical pitfall: Without validated screening tools, clinicians miss delirium in the majority of cases, particularly the hypoactive subtype which presents as confusion and sedation rather than agitation 1

Step 2: Identify and Treat Underlying Medical Causes

Conduct a targeted evaluation focusing on the most common precipitants 3:

• Medications: Review all medications immediately, particularly those with anticholinergic properties, benzodiazepines, and opioids 2, 3
• Infections: Check for urinary tract infections, pneumonia, and other sources of infection with appropriate cultures and imaging 2, 3
• Metabolic derangements: Order basic metabolic panel, complete blood count, and urinalysis to identify electrolyte abnormalities, hypoxia, or organ dysfunction 2, 3
• Alcohol or drug withdrawal: Assess for withdrawal symptoms if the patient has history of alcohol or sedative-hypnotic use 1, 4
• Pain: Evaluate and treat pain, preferably with nonopioid medications 2

Implement Multicomponent Nonpharmacologic Interventions

This is the foundation of delirium management and should be initiated immediately, as approximately one-third of delirium cases can be prevented or reversed through risk-factor modification. 1, 2

Cognitive and Environmental Interventions

• Reorientation: Regularly explain to the patient where they are, who you are, and your role 5, 2
• Environmental modifications: Ensure adequate lighting, place a visible clock and calendar in the room, and minimize room changes 1, 5, 2
• Continuity of care: Assign consistent staff members to care for the patient 5, 2
• Cognitive stimulation: Introduce therapeutic activities and facilitate regular family visits 1, 5, 2

Physical and Physiological Interventions

• Mobilization: Promote early mobilization and walking as tolerated 1, 2
• Sensory optimization: Ensure hearing aids and eyeglasses are in place and functioning 1, 2
• Hydration and nutrition: Maintain adequate fluid intake and nutritional support 1, 2
• Oxygenation: Address hypoxia and optimize oxygen delivery 1, 2
• Sleep hygiene: Reduce noise and interruptions during sleep hours, maintain normal day-night cycles 1, 2

Pharmacologic Management: When and What to Use

Avoid antipsychotics and benzodiazepines for routine delirium treatment, particularly for hypoactive delirium. 2

Indications for Pharmacologic Intervention

Consider low-dose antipsychotics only for 2:

• Severely agitated patients with distressing psychotic symptoms
• Patients threatening substantial harm to themselves or others
• Symptoms refractory to nonpharmacologic interventions

Key Pharmacologic Principles

• Use the lowest effective dose for the shortest possible duration 2
• Establish a taper plan at the time of prescription, as ICU antipsychotic use often leads to prolonged administration after discharge 1
• Monitor for extrapyramidal symptoms and other adverse effects 2
• Critical caveat: No high-quality evidence supports antipsychotic use for delirium treatment, and this remains off-label use 1, 6

Special Consideration: Alcohol Withdrawal Delirium

If alcohol withdrawal is suspected 4, 5:

• Timeline awareness: Delirium tremens typically begins 48-72 hours after last drink, with peak severity at 3-5 days 4
• Early intervention: Initiate benzodiazepines within the first 6-24 hours to prevent progression to delirium tremens 4
• Thiamine supplementation: Always provide thiamine to patients with alcohol use disorder 5
• Long-acting benzodiazepines (diazepam, chlordiazepoxide) provide superior protection against seizures and delirium compared to shorter-acting agents 4

Monitoring and Follow-Up

• Reassess mental status regularly using the CAM 5, 2
• Adjust interventions based on symptom control and patient distress 5, 2
• Provide educational support and written information about delirium to families 2
• Important context: Delirium is associated with increased mortality, prolonged hospitalization, and development of long-term cognitive impairment 1

Why This Approach Matters

Long-term care residents are at particularly high risk for delirium because most are over 65 years old and many have cognitive impairment or dementia—both factors that increase delirium risk more than 5-fold 1. The multicomponent prevention approach is cost-effective, reducing both costs and improving health outcomes compared to usual care 1. Delirium is a distressing experience for patients and families, and early detection through validated screening allows for reassurance and prompt intervention 1, 7.