How is delirium managed?

Management of Delirium

Delirium management requires immediate identification and treatment of underlying medical causes while simultaneously implementing non-pharmacological interventions as first-line therapy, reserving antipsychotics only for moderate-to-severe symptoms or when behavioral disturbances pose safety risks. 1

Immediate Assessment and Diagnosis

• Use the Confusion Assessment Method (CAM) or its variants (3D-CAM, CAM-ICU, Brief CAM) to diagnose delirium, which has 82-100% sensitivity and 89-99% specificity 1, 2, 3
• Obtain collateral history from family or caregivers to establish the patient's baseline cognitive function and the acute time course of changes (hours to days) 1
• Perform repeated assessments throughout the day, as delirium symptoms fluctuate substantially within minutes to hours depending on subtype (hyperactive, hypoactive, mixed) 1
• Recognize hypoactive delirium specifically, as it presents with cognitive slowing and sedated appearance, is more common in older adults, carries higher mortality risk, and is frequently missed 1

Identify and Treat Underlying Causes

This is the cornerstone of delirium management and must occur in parallel with symptom control. 1

• Obtain appropriate laboratory studies immediately: complete metabolic panel, complete blood count, urinalysis, chest radiograph, and consider blood cultures if infection suspected 1
• Common precipitating causes to evaluate: infection (especially urinary tract infection and pneumonia), toxic-metabolic disorders, electrolyte and hydration disturbances, hypoxia, organ failure, medications, and intoxication/withdrawal 1
• Review and eliminate delirium-inducing medications: steroids, anticholinergics, benzodiazepines (unless treating alcohol withdrawal), and consider opioid rotation if neurotoxicity suspected 1
• Two or more coexisting causes are frequently present, so continue searching even after identifying one precipitant 1

Non-Pharmacological Interventions (First-Line)

Maximize these interventions before using any pharmacological treatment. 1, 4

• Implement reorientation strategies: frequent verbal reorientation by staff, visible clocks and calendars, family presence when possible 1, 5
• Optimize sleep-wake cycle: minimize nighttime disruptions, ensure adequate daytime light exposure, maintain sleep hygiene 1
• Provide cognitive stimulation: engage patient in conversation, encourage use of glasses and hearing aids 1
• Ensure environmental safety: remove unnecessary tubes and catheters, minimize restraints, provide adequate lighting 1, 5
• Maintain hydration and nutrition, mobilize early when medically appropriate 5

Pharmacological Management (Second-Line)

Moderate Delirium

Use oral antipsychotics only after non-pharmacological interventions have been maximized. 1

• Olanzapine (oral): Start 2.5-5 mg, titrate to symptom control 1, 6
• Quetiapine: Start 12.5-25 mg, titrate as needed 1, 6
• Risperidone: Alternative option with similar efficacy to haloperidol but fewer side effects 6
• Haloperidol (oral): 0.5-1 mg, though atypical antipsychotics have fewer extrapyramidal side effects 1, 6

Severe Delirium with Agitation

When behavioral disturbances pose imminent risk to patient or staff safety, pharmacological intervention may be required as initial treatment to facilitate medical evaluation. 4

• Haloperidol: First-line for severe agitation, can be given IV/IM for rapid control 1, 7
• Olanzapine: Effective alternative for severe symptoms 1
• Chlorpromazine: Use only in bed-bound patients due to hypotensive effects 1
• Add lorazepam (benzodiazepine) only for agitation refractory to high-dose antipsychotics, as therapeutic levels of antipsychotics prevent paradoxical excitation 1

Critical Contraindication

Do NOT use benzodiazepines as initial treatment for delirium unless the patient has alcohol or sedative-hypnotic withdrawal. 1, 5

Special Populations and Situations

End-of-Life Delirium

• Focus on symptom management and family support when delirium results from disease progression in dying patients 1
• Increase doses and/or change routes of administration of neuroleptics and benzodiazepines to ensure adequate symptom control 1
• Consider palliative sedation for refractory delirium after consultation with palliative care specialist 1

Monitoring and Follow-Up

• Measure delirium severity over time using validated scales to ensure appropriate response and resolution 1
• Titrate all symptom-management medications to optimal relief while monitoring for side effects 1
• Implement taper plans for any antipsychotic prescribed, as these should not be continued long-term without reassessment 3

Critical Pitfalls to Avoid

• Missing hypoactive delirium: This subtype appears as lethargy rather than agitation and carries the highest mortality risk 1
• Using benzodiazepines inappropriately: These worsen delirium except in alcohol/sedative withdrawal 1, 5
• Treating symptoms without addressing underlying cause: Delirium is a medical emergency requiring identification of precipitants 1
• Delaying diagnosis: Mortality doubles when delirium is missed 1

Family Support and Education

• Provide information about delirium preventively and at repeated intervals to family members 8
• Support caregivers in managing this distressing condition, as it significantly impacts both patient and family 1, 8