What is the management approach for delirium?

Management of Delirium

The cornerstone of delirium management is identifying and treating underlying causes while implementing non-pharmacological interventions; pharmacological treatment should be reserved only for patients with distressing symptoms or safety concerns, and antipsychotics like haloperidol and risperidone should be avoided as they show no benefit in mild-to-moderate delirium. 1, 2

Immediate Assessment and Diagnosis

Use validated screening tools systematically rather than relying on clinical gestalt alone, as delirium is frequently missed without structured assessment 1:

• Apply the Confusion Assessment Method (CAM) or CAM-ICU for detection, which takes less than 2 minutes and has 82-100% sensitivity and 89-99% specificity 1, 2, 3
• The ICDSC (Intensive Care Delirium Screening Checklist) is an alternative 8-domain tool that can be used based on clinician preference 1
• Assess arousal level first using sedation scales, then proceed to delirium screening 1
• Recognize that delirium is a medical emergency with mortality twice as high if missed 1

Identify and Treat Underlying Causes

Conduct a comprehensive initial assessment to identify precipitating factors 1, 2:

Common Reversible Causes to Address:

• Infections (particularly urinary tract infections and pneumonia) - treat if consistent with goals of care 1
• Medications - review and discontinue deliriogenic drugs, especially benzodiazepines 1, 2
• Metabolic disturbances:
  • Hypercalcemia: Administer IV bisphosphonates (pamidronate or zoledronic acid) which can reverse delirium in substantial cases 1, 2
  • Hypomagnesemia: Provide magnesium replacement 1, 2
  • SIADH: Discontinue implicated medications, restrict fluids, ensure adequate oral salt intake 1
• Opioid-induced neurotoxicity: Consider opioid rotation to fentanyl or methadone 1, 2
• Pain, hypoxia, urinary retention, constipation, and dehydration 2

Non-Pharmacological Interventions (First-Line)

Implement multicomponent non-pharmacological strategies as the primary intervention, which can reduce delirium incidence by 40% 2, 4:

Environmental Modifications:

• Ensure adequate lighting and clear signage 2, 5
• Provide visible clock and calendar for orientation 2, 5
• Minimize room changes and transfers 2, 5
• Create a calming, quiet environment 2
• Implement sleep hygiene measures to promote normal sleep-wake cycles 2

Cognitive and Social Interventions:

• Regularly reorient the patient by explaining where they are, who they are, and your role 2, 5
• Introduce cognitively stimulating activities 2, 5
• Facilitate regular visits from family and friends 2, 5
• Ensure continuity of care with familiar healthcare team members 5

Basic Care:

• Ensure adequate hydration and nutrition 2
• Promote early mobilization when safe, as this may shorten mechanical ventilation duration and accelerate delirium resolution 1

Pharmacological Management (Second-Line Only)

Limit pharmacological interventions to patients with distressing symptoms (such as perceptual disturbances) or safety concerns where the patient poses risk to themselves or others 1, 2:

What NOT to Use:

• Avoid haloperidol and risperidone as they demonstrate no benefit in symptomatic management of mild-to-moderate delirium 1, 2
• Do not use benzodiazepines as first-line agents, as they are deliriogenic and increase fall risk 1 - Exception: First-line for alcohol or benzodiazepine withdrawal 1
• No pharmacological prophylaxis is recommended for delirium prevention 1

Medication Options When Necessary:

• Olanzapine may offer benefit for symptomatic management 1, 2
• Quetiapine may offer benefit (available in oral formulations only; sedation may be advantageous in hyperactive delirium) 1, 2
• Aripiprazole may offer benefit 1, 2
• Dexmedetomidine is the drug of choice in ICU patients with severe agitation and those weaning from mechanical ventilation, and may improve hyperactive delirium resolution 1
• Methylphenidate may improve cognition in hypoactive delirium without delusions or perceptual disturbances 1

Critical Prescribing Principles:

• Use the lowest effective dose for the shortest time possible 1
• Monitor for extrapyramidal side effects, particularly with first-generation antipsychotics 2
• Accompany any antipsychotic prescription with an appropriate taper plan 4

ICU-Specific Strategies

Implement the ABCDEF Bundle in intensive care settings, which has been associated with reduced delirium, shorter ventilation time, and survival benefits 1:

• Use short-acting sedatives (propofol, dexmedetomidine) over benzodiazepines in mechanically ventilated patients 1
• Access early mobility and physical rehabilitation to shorten mechanical ventilation duration 1

Family and Staff Support

Provide written information to family members about delirium definition, causes, symptoms, evolution, and management 1, 2:

• Offer guidance on appropriate responses and non-pharmacological interventions 1, 2
• Provide educational and psychological support for families experiencing distress 2
• Offer formal debriefing opportunities for patients after delirium resolution and for healthcare teams after challenging cases 1

Monitoring and Follow-Up

• Regularly reassess mental status using standardized tools, as delirium fluctuates throughout the day 2, 5, 3
• Adjust treatment approaches based on symptom control and patient distress 2, 5
• Wait 2-4 weeks after complete delirium resolution before performing formal cognitive impairment testing 3
• Arrange follow-up with primary care for ongoing cognitive screening after discharge 4

Common Pitfalls to Avoid

• Failing to use validated screening tools - clinical gestalt alone misses most cases 1, 6
• Using antipsychotics as first-line treatment without attempting non-pharmacological interventions 2, 4
• Prescribing benzodiazepines for non-withdrawal delirium, which worsens outcomes 1
• Discharging patients with unresolved symptoms without appropriate follow-up 7
• Not recognizing delirium superimposed on dementia, which has grave prognostic implications including accelerated cognitive decline, longer hospitalization, and higher mortality 3