What is the initial workup and treatment for a patient with delirium?

Delirium Workup and Treatment

Initial Clinical Assessment

Delirium requires immediate clinical evaluation by a trained healthcare professional using DSM or ICD criteria when any cognitive, emotional, or psychomotor changes are observed. 1

Key Sentinel Changes to Observe

• Impaired concentration, slow responses, or withdrawal 1
• Sleep disturbances, hallucinations, or confusion 1
• Agitation, restlessness, or mood changes 1
• Monitor hospitalized patients at least daily for these fluctuations 1

Note: Screening tools are insufficient for diagnosis—clinical assessment by an expert is required to confirm delirium. 1

Comprehensive Workup for Reversible Causes

Identify precipitating factors through systematic evaluation, as 20-50% of delirium episodes in non-dying patients are reversible. 1, 2

Laboratory Investigations

• Electrolytes: Sodium (SIADH), potassium, calcium (hypercalcemia), magnesium 1
• Renal function: BUN, creatinine (medication accumulation) 1
• Infection markers: WBC count, cultures if indicated 1
• Metabolic panel: Glucose, liver function tests 2

Medication Review

• Opioids: Most common cause in cancer patients (60% of episodes) 3
• Anticholinergics, benzodiazepines, PPIs: Discontinue if possible 1
• Chemotherapy/immunotherapy: Consider treatment-related toxicity 1

Additional Workup Based on Clinical Context

• Hypoxia assessment: Oxygen saturation, arterial blood gas 1
• CNS imaging (CT/MRI): If focal neurological signs or unexplained delirium 1
• Urinary retention/constipation: Physical examination 2

Critical Pitfall: Medication-induced delirium is usually reversible, whereas hypoxic encephalopathy and organ failure are associated with non-reversibility. 1

Treatment Algorithm

Step 1: Non-Pharmacological Interventions (First-Line)

Maximize non-pharmacological strategies before any medication use—this is the primary treatment approach. 2

• Environmental modifications: Reorientation, quiet environment, day-night rhythm optimization 2
• Sensory optimization: Ensure glasses/hearing aids are available 2
• Sleep hygiene: Minimize nighttime disruptions 2
• Early mobilization: Remove unnecessary tubes/catheters 2
• Cognitive stimulation: Frequent reorientation by familiar caregivers 2

Step 2: Treat Specific Reversible Causes

Opioid-Induced Delirium

Opioid rotation to fentanyl or methadone is efficacious when opioid-induced neurotoxicity is present. 1

• Reduce equianalgesic dose by 30-50% when switching 1
• Treatment success achieved in 65% by day 3,90% by day 7 1

Hypercalcemia

Bisphosphonates (IV pamidronate or zoledronic acid) reverse delirium in substantial numbers of hypercalcemic patients. 1

SIADH

Discontinue implicated medications, restrict fluids, and ensure adequate oral salt intake. 1

Hypomagnesemia

Magnesium replacement is recommended. 1

Infection

Treat infections if consistent with patient's goals of care. 1

Hydration

• Limited evidence for routine hydration in delirium management 1
• Clinically assisted hydration is not more effective than placebo for prevention 1

Step 3: Pharmacological Management (Reserved for Severe Agitation)

Medications should only be used for severe agitation posing safety risks—routine antipsychotic use does not improve outcomes and may cause harm. 2

Mild-to-Moderate Delirium

Haloperidol and risperidone have NO demonstrable benefit in mild-to-moderate delirium and are NOT recommended. 1, 2

Consider olanzapine or quetiapine as they may offer benefit with fewer side effects: 1, 2

• Olanzapine: May offer benefit for symptomatic management 1
• Quetiapine: May offer benefit for symptomatic management 1
• Aripiprazole: May offer benefit 1

Severe Delirium with Agitation

For severe agitation, use haloperidol, olanzapine, or chlorpromazine at the lowest effective dose for the shortest duration. 4, 5

• Haloperidol preferred in ICU settings due to multiple administration routes and fewer anticholinergic effects 5
• Atypical antipsychotics (risperidone, olanzapine) have lower propensity for over-sedation and movement disorders 5

Hypoactive Delirium

Methylphenidate may improve cognition in hypoactive delirium without delusions or perceptual disturbances. 1, 3

Refractory Agitation

Benzodiazepines (lorazepam) are effective for sedation when agitation is refractory to antipsychotics. 1, 5

• Critical Warning: Benzodiazepines alone can worsen delirium—only use for alcohol/sedative withdrawal or refractory agitation 2

Step 4: Daily Reassessment

Discontinue antipsychotics immediately once acute symptoms resolve and reassess daily. 2

Common Pitfalls to Avoid

• Hypoactive delirium is underdiagnosed: Most prevalent subtype in palliative care, often missed due to subtle presentation 2
• Mistaking agitation for pain: Results in higher opioid doses that worsen delirium 2
• Using benzodiazepines alone: Worsens delirium except in alcohol/sedative withdrawal 6, 2
• Ignoring reversible causes: Never use medications without addressing underlying precipitants 6, 2

Family Education and Support

Provide written information about delirium to families pre-emptively and at repeated intervals, supplemented with psychological support from trained staff. 1, 2

• Families need education about the fluctuating nature and distressing symptoms 1
• Support caregivers in coping with this condition 4