From the Guidelines
Delirium is a medical emergency that requires prompt recognition and management to reduce morbidity, mortality, and improve quality of life. The primary management approach is to identify and treat underlying causes while providing supportive care. Common causes include medications (especially anticholinergics, benzodiazepines, and opioids), infections (particularly UTIs and pneumonia in the elderly), metabolic disturbances (electrolyte abnormalities, hypoglycemia), hypoxia, alcohol withdrawal, and sleep deprivation. Management begins with a thorough medical evaluation including physical examination, laboratory tests, and medication review to identify the underlying cause. Non-pharmacological interventions are first-line and include reorientation strategies (clocks, calendars, familiar objects), ensuring adequate hydration and nutrition, promoting normal sleep-wake cycles, early mobilization, and involving family members.
Some key points to consider in the management of delirium include:
- Identifying and treating underlying causes
- Using non-pharmacological interventions as first-line treatment
- Reserving pharmacological management for severe agitation that poses safety risks
- Using low-dose antipsychotics, such as haloperidol or quetiapine, for short-term management of agitation
- Avoiding benzodiazepines except in cases of alcohol withdrawal delirium
- Implementing prevention strategies, such as maintaining sensory input, avoiding unnecessary catheterization, minimizing room changes, and early mobilization
According to the most recent study 1, delirium is a defined and diagnosable medical condition that is considered a medical emergency. Early detection and accurate diagnosis are extremely important because mortality in patients may be twice as high if the diagnosis of delirium is missed. The economic impact of delirium in the United States is profound, with total costs estimated at $38 to $152 billion each year.
In terms of specific management strategies, the study 1 recommends a therapeutic environment, preventative measures, and a multicomponent intervention package tailored for persons at risk for delirium. This package includes assessment and modification of key clinical factors that may precipitate delirium, such as cognitive impairment or disorientation, dehydration or constipation, hypoxia, infection, immobility or limited mobility, several medications, pain, poor nutrition, sensory impairment, and sleep disturbance.
Overall, the management of delirium requires a comprehensive and multidisciplinary approach that prioritizes prompt recognition, identification and treatment of underlying causes, and supportive care to reduce morbidity, mortality, and improve quality of life.
From the Research
Delirium Causes and Management
Delirium is a common syndrome in hospitalized patients, particularly in the elderly, and is associated with prolonged hospital stay and increased morbidity and mortality 2. The causes of delirium can be varied, but it is often related to underlying medical conditions, medications, or other factors.
Diagnosis and Management
Diagnosing delirium can be aided by using DSM-IV criteria, the Delirium Symptom Interview, or the confusion assessment method 3. Management of delirium must include investigation and treatment of underlying causes and general supportive measures, such as providing optimal levels of stimulation, reorienting patients, education, and supporting families 3.
Pharmacologic Management
Pharmacologic management of delirium should be considered only for specific symptoms or behaviors, such as aggression, severe agitation, or psychosis 3. The mainstay of pharmacologic management of delirium remains typical antipsychotics, primarily haloperidol, although atypical antipsychotics such as risperidone, olanzapine, and quetiapine are also used 4.
- Atypical antipsychotics have been found to be as effective as haloperidol in managing delirium, with a lower incidence of extrapyramidal adverse effects 2, 5, 6.
- Risperidone, olanzapine, and quetiapine have been found to be effective in treating delirium, with response rates ranging from 70% to 85% 6.
- Haloperidol remains a time-tested treatment, particularly in critical care, but may be associated with a higher incidence of extrapyramidal side effects compared to atypical antipsychotics 5.
- The frequency of adverse reactions and side effects has been found to be lower with the use of atypical antipsychotic medications compared to haloperidol 6.
Key Considerations
- Delirium is frequently underdiagnosed in clinical practice and should be suspected with acute changes in behavior 3.
- Careful investigation of the underlying cause of delirium is necessary to permit appropriate management 3.
- Atypical antipsychotics may be preferable to haloperidol when looking to avoid neurological side effects, but more research is needed to fully establish their efficacy and safety in managing delirium 5, 6.