How is delirium managed?

Management of Delirium

Delirium management requires immediate identification and treatment of underlying medical causes while simultaneously implementing non-pharmacological interventions first, reserving antipsychotic medications for moderate to severe cases or when non-pharmacological approaches fail. 1

Immediate Assessment and Diagnosis

• Use the Confusion Assessment Method (CAM) or similar validated instruments to confirm delirium diagnosis, focusing on acute onset, fluctuating course, inattention, and altered consciousness 1
• Obtain history from knowledgeable informants to establish baseline cognitive function and timeline of changes, as this is the foundation of accurate diagnosis 1
• Perform repeated assessments throughout the day since cognitive status fluctuates substantially within hours, particularly in hypoactive delirium which carries higher mortality risk 1
• Recognize that delirium is a medical emergency with mortality twice as high if missed, requiring urgent intervention 1

Identify and Treat Underlying Causes

Obtain appropriate laboratory studies and imaging immediately to identify reversible causes including infection (especially urinary tract infections and pneumonia), toxic-metabolic disorders, electrolyte disturbances, hypoxia, organ failure, and medication effects 1

• Eliminate or reduce delirium-inducing medications, particularly steroids, anticholinergics, and benzodiazepines 1
• Evaluate for common precipitants: two or more coexisting causes are frequently present 1
• In cancer patients, assess for hypercalcemia, infection, and treatment-related neurotoxicity 2
• Consider opioid rotation if delirium appears related to opioid neurotoxicity 1

Non-Pharmacological Interventions (First-Line)

Maximize non-pharmacological interventions before using medications, as these are the cornerstone of delirium management 1, 3

• Implement frequent reorientation by staff and family members 1, 4
• Provide cognitive stimulation and maintain normal sleep-wake cycles with sleep hygiene measures 1
• Ensure adequate hydration, nutrition, and pain control 3
• Optimize the environment: reduce noise, provide adequate lighting during day, minimize nighttime disruptions 3, 4
• Provide 24-hour companion or sitter when possible for patient safety 5
• Remove unnecessary tubes, catheters, and monitoring devices 1

Pharmacological Management

Moderate Delirium

For moderate delirium symptoms, use oral antipsychotics as second-line treatment when non-pharmacological approaches are insufficient 1

• Olanzapine is recommended for moderate delirium (starting dose 5-10 mg daily, with additional 2.5 mg as needed) 1, 2, 6
• Quetiapine is an effective alternative for moderate symptoms 1, 2, 6
• Risperidone is also efficacious with fewer side effects than haloperidol 6
• Haloperidol remains an option but carries higher risk of extrapyramidal symptoms 1, 6

Severe Delirium with Agitation

For severe delirium with agitation, use antipsychotic neuroleptics such as haloperidol, olanzapine, or chlorpromazine 1, 2

• Titrate doses to optimal symptom relief, monitoring closely for response 1
• Use intravenous chlorpromazine only in bed-bound patients due to hypotensive effects 1
• Add benzodiazepines (lorazepam) only for agitation refractory to high-dose neuroleptics, not as initial treatment 1
• Benzodiazepines should be avoided as initial therapy except in alcohol or sedative-hypnotic withdrawal 1, 4

Special Considerations

Hypoactive Delirium

• Recognize that hypoactive delirium presents with cognitive slowing, motor retardation, and sedated appearance rather than agitation 1
• This subtype is more common in older adults and carries greater mortality risk, yet is frequently underdiagnosed 1

End-of-Life Delirium

• In dying patients with refractory delirium from disease progression, focus on symptom management and family support 1
• Increase neuroleptic and benzodiazepine doses and consider route changes to ensure adequate symptom control 1
• Consider palliative sedation for refractory terminal delirium after consultation with palliative care specialists 1

Monitoring and Follow-Up

• Measure delirium severity over time using validated scales to ensure appropriate response and resolution 1
• Continue treating underlying causes while managing symptoms 1, 3
• Provide ongoing education and support to caregivers throughout the episode, as delirium is highly distressing for families 1, 2

Critical Pitfalls to Avoid

• Never use benzodiazepines as first-line treatment except in alcohol or sedative withdrawal, as they can worsen delirium 1, 4
• Do not miss hypoactive delirium by only screening for agitated patients 1
• Avoid attributing symptoms to primary psychiatric disorders without ruling out medical causes first 1, 4
• Do not delay treatment while awaiting complete workup, as early intervention reduces mortality 1