What is the best approach to manage delirium in a patient?

Management of Delirium

The best approach to managing delirium prioritizes multicomponent nonpharmacologic interventions as first-line treatment, with antipsychotics reserved strictly for severe agitation that threatens patient or staff safety. 1, 2

Immediate Assessment and Recognition

• Screen all at-risk patients systematically using validated tools like the Confusion Assessment Method (CAM), CAM-ICU, or the 3-Minute Diagnostic Assessment rather than relying on clinical gestalt alone 1, 2, 3
• Target high-risk groups: patients ≥65 years, those with cognitive impairment/dementia, severe illness, or hip fracture (all have >5-fold increased delirium risk) 1
• Assess arousal level first with sedation scales, then evaluate for delirium features: acute onset, fluctuating course, inattention, and altered cognition 1

First-Line: Multicomponent Nonpharmacologic Interventions

These interventions prevent approximately one-third of delirium cases and form the cornerstone of both prevention and treatment. 1

Core Environmental and Supportive Measures (Must implement ALL consistently):

• Reorientation: Repeatedly orient patient to person, place, and time; explain your role; ensure visible clock and calendar 1, 4
• Early mobilization: Mobilize and ambulate patients early and frequently 1
• Sleep hygiene: Reduce nighttime noise, minimize unnecessary stimuli, use nonpharmacologic sleep approaches 1
• Sensory optimization: Provide adaptive equipment for vision and hearing impairment 1
• Nutrition and hydration: Maintain adequate intake and correct dehydration 1, 5
• Cognitive stimulation: Introduce therapeutic activities and facilitate regular family visits 1, 4
• Minimize transfers: Avoid moving patients between rooms/wards unless absolutely necessary 1, 4

Address Reversible Causes Immediately:

• Medication review: Reduce or eliminate deliriogenic medications (benzodiazepines, anticholinergics, steroids) 1, 6
• Treat precipitants: Manage infection, pain, hypoxia, hypoperfusion, fever, electrolyte imbalances, and constipation 1, 6
• Opioid management: Consider opioid dose reduction or rotation if neurotoxicity suspected 1, 6

Pharmacologic Management: Reserved for Specific Indications Only

Critical Principle:

Antipsychotics should ONLY be used for severe agitation that poses safety risk or threatens interruption of essential medical therapies—NOT for routine delirium treatment. 2, 7

For Moderate Delirium with Agitation:

• First-choice agents: Oral haloperidol, risperidone, olanzapine, or quetiapine 1, 6
• Preferred over haloperidol: Olanzapine, quetiapine, or aripiprazole for moderate symptoms 6

For Severe Delirium with Dangerous Agitation:

• Parenteral antipsychotics: Haloperidol (2-5 mg), olanzapine, or chlorpromazine 1, 6
• Chlorpromazine caveat: Use only in bed-bound patients due to hypotensive effects 1
• Escalation strategy: Increase neuroleptic doses and/or change routes (oral to parenteral) BEFORE adding additional agents 6

For Refractory Agitation:

• Add benzodiazepine ONLY after high-dose neuroleptics fail: Lorazepam (1-5 mg) or midazolam (1-5 mg) can be added to antipsychotics 1, 6
• Critical safety point: Therapeutic neuroleptic levels prevent paradoxical excitation from benzodiazepines 1, 6
• NEVER use benzodiazepines as monotherapy for delirium—they worsen confusion and increase fall risk 6, 8

For ICU Patients:

• Sedation preference: Use short-acting agents (propofol, dexmedetomidine) over benzodiazepines 1
• Dexmedetomidine benefit: Improves hyperactive delirium resolution in mechanically ventilated and non-intubated patients 1, 6

Special Populations and Refractory Cases

Dying Patients with Refractory Delirium:

• Palliative sedation: Consider after consultation with palliative care specialist and/or psychiatrist 1, 6
• Remove unnecessary interventions: Discontinue non-essential medications and tubes 1
• Last resort: Phenobarbital for truly refractory cases 6

Hypoactive Delirium (Often Underdiagnosed):

• Most prevalent subtype in palliative care settings 1
• Focus on reversible causes: Sepsis, pain, medications, metabolic issues 1
• Rule out fearful hallucinations/delusions even in hypoactive presentation 1

Common Pitfalls to Avoid

• High-fidelity implementation failure: These interventions must be delivered to ALL at-risk patients ALL the time, not just some patients some of the time 1
• Premature pharmacologic intervention: Maximize nonpharmacologic approaches before using medications 1, 7
• Using antipsychotics for prevention: No convincing evidence supports pharmacologic prevention 2, 9
• Benzodiazepine monotherapy: Never appropriate except for alcohol/benzodiazepine withdrawal 6, 8
• Delayed recognition: Delirium is underrecognized and underdiagnosed without systematic screening 1

Monitoring and Follow-up

• Severity assessment: Use tools like CAM-Severity Score to monitor treatment response and stratify risk 2
• Ongoing surveillance: Delirium may persist for months in vulnerable patients despite resolution of acute illness 5
• Caregiver education: Support and educate families about this distressing condition 1