What is the treatment approach for delirium?

Delirium Treatment

Prioritize multicomponent non-pharmacological interventions as first-line treatment for all delirium cases, reserving antipsychotics exclusively for severe agitation that poses immediate safety risks—and even then, haloperidol and risperidone should be avoided in mild-to-moderate delirium as they provide no demonstrable benefit. 1, 2

Immediate Assessment and Reversal of Underlying Causes

Every patient with delirium requires comprehensive evaluation to identify and treat precipitating factors 1, 2:

• Metabolic derangements: Check electrolytes, particularly magnesium (replace if low), calcium (treat hypercalcemia with IV bisphosphonates like pamidronate or zoledronic acid), and sodium (manage SIADH with fluid restriction and adequate oral salt intake) 2
• Medications: Review all medications for deliriogenic agents—particularly opioids >80mg parenteral morphine equivalent/day, benzodiazepines ≥2mg lorazepam equivalent/day, anticholinergics, corticosteroids, and anticonvulsants 2, 1
• Opioid-induced neurotoxicity: If present, rotate to fentanyl or methadone 2
• Infections: Treat if consistent with goals of care 2
• Urinary retention or constipation: Address immediately 1
• Anticancer treatments: Consider withdrawal if chemotherapy or immunotherapy is implicated 2

Non-Pharmacological Interventions (First-Line for All Patients)

Maximize these evidence-based strategies before considering any medication 1, 2:

• Reorientation: Provide repeated orientation to time, place, and person 1
• Sensory optimization: Ensure glasses and hearing aids are in place and functioning 1
• Sleep hygiene: Minimize nighttime disruptions, reduce noise, maintain day-night rhythm 1, 2
• Early mobilization: Get patients out of bed and moving as soon as medically safe 2, 1
• Cognitive stimulation: Engage patients in conversation and activities 1
• Environmental modifications: Remove unnecessary tubes, catheters, and restraints 1
• Hydration and nutrition: Maintain adequate intake (though clinically assisted hydration does not prevent delirium) 2, 1

The ABCDEF Bundle has shown associations with reduced delirium duration and improved survival in ICU settings 2.

Pharmacological Management (Reserved for Severe Agitation Only)

When NOT to Use Antipsychotics

Do not use haloperidol or risperidone for mild-to-moderate delirium—they have no demonstrable benefit and are explicitly not recommended 2, 1. This represents high-quality evidence from randomized trials 2.

When to Consider Antipsychotics

Use medications only when severe agitation poses safety risks to patient or staff 1. Choose from these options:

• Olanzapine: May offer benefit for symptomatic management 2, 3
• Quetiapine: May offer benefit with fewer extrapyramidal effects 2, 3
• Aripiprazole: May offer benefit 2

Critical dosing principle: Use the lowest effective dose for the shortest duration possible, and discontinue immediately once acute distressing symptoms resolve 1.

Special Considerations

• Hypoactive delirium without delusions/perceptual disturbance: Consider methylphenidate to improve cognition if no reversible cause identified 2
• Severe symptomatic distress: Benzodiazepines (particularly lorazepam) are effective for providing sedation and anxiolysis in acute severe delirium 2, 3
• ICU settings: Dexmedetomidine may improve hyperactive delirium resolution and is preferred over benzodiazepines for sedation 2

Critical Pitfalls to Avoid

• Underdiagnosing hypoactive delirium: This is the most prevalent subtype in palliative care but often missed due to subtle presentation 1
• Mistaking agitation for pain: This leads to increased opioid doses that worsen delirium 1
• Using benzodiazepines inappropriately: These worsen delirium except in alcohol/sedative withdrawal or when agitation is refractory to antipsychotics 1
• Routine antipsychotic use: This does not improve delirium outcomes and may cause harm 1

Monitoring and Reassessment

• Assess delirium daily using validated tools (CAM-ICU or ICDSC) 2, 1
• Reassess need for pharmacological intervention daily 1
• Search for and manage ongoing risk factors including sepsis, pain, hypoperfusion, fever, and electrolyte imbalances 2

Family Support

Provide written information about delirium to families pre-emptively and at repeated intervals, supplemented with educational and psychological support from trained staff 2, 1. This is particularly important as the patient's condition declines 2.