How is delirium managed?

Management of Delirium

Delirium management begins with maximizing non-pharmacological interventions (reorientation, cognitive stimulation, sleep hygiene) while simultaneously identifying and treating reversible causes, followed by antipsychotic medications for moderate-to-severe symptoms, with olanzapine, risperidone, or quetiapine preferred over haloperidol for most cases. 1

Initial Assessment and Diagnosis

• Use validated screening tools like the Confusion Assessment Method (CAM) to establish the diagnosis, focusing on acute onset, fluctuating course, inattention, and altered level of consciousness 1, 2
• Obtain collateral history from family or caregivers to determine baseline cognitive function and the timeline of changes, as this is essential for differentiating delirium from dementia or primary psychiatric disorders 1, 3
• Perform repeated assessments throughout the day since cognitive status fluctuates substantially due to variations in arousal, attention, and psychomotor state 1
• Recognize that hypoactive delirium (presenting with cognitive slowing, motor slowing, and sedated appearance) is commonly underdiagnosed but carries higher morbidity and mortality risk 1

Identify and Treat Underlying Causes

• Obtain appropriate laboratory studies and imaging to identify precipitating factors including infection, toxic-metabolic disorders, electrolyte disturbances, hypoxia, organ failure, and medication effects 1, 2
• Eliminate or reduce delirium-inducing medications, particularly steroids, anticholinergics, and unnecessary polypharmacy 1, 3
• Address specific medical conditions such as hypercalcemia (especially in cancer patients), infections, and hydration status 1, 4
• Consider opioid rotation if delirium appears related to opioid neurotoxicity 1

Non-Pharmacological Interventions (First-Line)

• Implement environmental modifications including frequent reorientation by staff, cognitive stimulation activities, and optimization of sleep-wake cycles 1, 3
• Provide a 24-hour companion or sitter when feasible to enhance safety and reorientation 5
• Educate family members about delirium preventively and at repeated intervals, providing support for caregivers managing this distressing condition 1, 4
• Remove unnecessary medical equipment, tubes, and devices that may contribute to confusion 1

Pharmacological Management

Moderate Delirium

• Use oral olanzapine, risperidone, or quetiapine as first-line antipsychotics for moderate delirium symptoms 1, 4
• Start olanzapine at 5 mg daily, titrating to 10 mg nightly with 2.5 mg as needed during the day based on response 5
• These atypical antipsychotics cause fewer extrapyramidal side effects compared to typical agents, which is particularly important in vulnerable populations 5, 6

Severe Delirium with Agitation

• Manage severe agitation with antipsychotic neuroleptics such as haloperidol, olanzapine, or chlorpromazine 1, 4
• Reserve intravenous chlorpromazine only for bed-bound patients due to hypotensive side effects 1
• Titrate dosages to optimal symptom relief while monitoring for adverse effects 1

Refractory Agitation

• Add a benzodiazepine such as lorazepam only for agitation refractory to high-dose neuroleptics, and only after therapeutic levels of antipsychotics are established to prevent paradoxical excitation 1, 6
• Do not use benzodiazepines as initial treatment for delirium in patients not already taking them (exception: alcohol or sedative-hypnotic withdrawal) 1, 3

Special Considerations

End-of-Life Care

• In dying patients with refractory delirium from disease progression, focus on symptom management rather than reversal 1
• Increase doses and/or change routes of administration for neuroleptic and benzodiazepine medications to ensure adequate symptom control 1
• Consider palliative sedation for refractory delirium after consultation with palliative care specialists 1

Common Pitfalls to Avoid

• Avoid using haloperidol as first-line in patients at risk for extrapyramidal symptoms, as it can dramatically worsen rigidity, bradykinesia, and tremor 5
• Do not attribute delirium symptoms to primary psychiatric disorders without first ruling out medical causes through proper history and examination 3
• Recognize that benzodiazepines alone (except for withdrawal syndromes) can worsen delirium and should be avoided as monotherapy 1, 3