What is the recommended workup and management for a patient with Intensive Care Unit (ICU) delirium?

ICU Delirium Workup

Routine monitoring for delirium using validated bedside instruments (CAM-ICU or ICDSC) should be performed at least every shift in all adult ICU patients, followed by systematic identification of underlying causes and immediate implementation of non-pharmacological interventions as first-line management. 1

Systematic Delirium Screening

• Use the Confusion Assessment Method for ICU (CAM-ICU) or Intensive Care Delirium Screening Checklist (ICDSC) as these are the most valid and reliable instruments with the strongest psychometric properties for detecting delirium in both mechanically ventilated and non-ventilated patients 1, 2
• Screen at least every shift, as delirium frequently presents as hypoactive (quiet) rather than hyperactive, and ICU personnel commonly underestimate its presence 1, 3
• Recognize that neither hallucinations nor delusions are required to diagnose delirium—the cardinal features are disturbed consciousness with inattention plus either cognitive changes or perceptual disturbances 1, 2

Identify Underlying Causes and Risk Factors

When delirium is detected, immediately assess for:

Baseline Risk Factors

• Preexisting dementia, history of hypertension, history of alcoholism, and high severity of illness at admission are the four baseline factors most strongly associated with ICU delirium 1, 4
• Recent coma, as this is an independent risk factor 1, 4

Precipitating Factors to Address

• Metabolic disturbances (electrolyte abnormalities, uremia, hepatic dysfunction, hypoglycemia) 3, 5
• Hypoxemia and respiratory failure 5
• Uncontrolled pain—assess using validated pain scales (BPS or CPOT for non-communicative patients) 1, 6
• Benzodiazepine use, as this may be a risk factor for developing delirium 1
• Alcohol or drug withdrawal syndromes—differentiate this from other causes as management differs 1
• Medications that may precipitate delirium (anticholinergics, sedatives) 3, 5
• Sepsis and infection 5
• Environmental factors impairing vision, hearing, and sleep 5

First-Line Non-Pharmacological Management

Early mobilization is the strongest evidence-based intervention to reduce both incidence and duration of delirium and should be implemented whenever feasible. 1, 2, 4

Implement the Following Interventions Immediately:

• Early mobilization and physical therapy to reduce delirium incidence, duration, ICU length of stay, and increase ventilator-free days 1, 2, 4
• Sleep promotion: Control light and noise, cluster patient care activities, decrease nighttime stimuli to protect sleep cycles 1, 4
• Cognitive stimulation and reorientation using familiar objects, clocks, calendars 2
• Environmental modifications: Ensure adequate daytime lighting, reduce sensory deprivation, optimize hearing aids and glasses 2
• Analgesia-first approach: Treat pain adequately before administering sedatives 1, 4
• Family engagement to provide familiar faces and voices 5

Sedation Strategy for Mechanically Ventilated Patients

• Maintain light levels of sedation using either daily sedation interruption or titration to light sedation targets (RASS -1 to 0) 1, 4
• Use dexmedetomidine rather than benzodiazepine infusions for sedation in mechanically ventilated patients at risk for or with established delirium (except in alcohol or benzodiazepine withdrawal) 1, 2, 4
• Avoid benzodiazepines when possible, as they are associated with higher delirium prevalence 1, 4
• Use the RASS or SAS scales to assess sedation depth 1

Pharmacological Considerations

What NOT to Use:

• Do not use haloperidol or atypical antipsychotics prophylactically to prevent delirium, as there is no evidence they reduce incidence or duration 1, 4
• Do not use rivastigmine—it is contraindicated as it increases mortality and prolongs delirium 2, 4, 6
• Avoid antipsychotics in patients with baseline QT prolongation, history of Torsades de Pointes, or those on QT-prolonging medications 1, 4

Limited Role for Antipsychotics:

• Haloperidol has no published evidence that it reduces delirium duration 1
• Atypical antipsychotics may reduce delirium duration but evidence is weak (Grade C), and they should not be used routinely 1, 2, 6
• Consider short-term use only for patients with significant distress from hallucinations/delusions with fearfulness, or agitation posing physical harm 2

When to Use Dexmedetomidine:

• For mechanically ventilated patients with delirium unrelated to alcohol or benzodiazepine withdrawal, use dexmedetomidine rather than benzodiazepines to reduce delirium duration 1, 2, 4
• For agitation precluding weaning or extubation in mechanically ventilated patients 2
• Avoid loading doses in hemodynamically unstable patients 4

Special Consideration: Alcohol/Benzodiazepine Withdrawal

• Benzodiazepines remain the mainstay for alcohol withdrawal syndrome, despite the general recommendation to avoid them for other causes of delirium 1
• Differentiate withdrawal-related delirium from other causes, as management differs significantly 1

Critical Pitfalls to Avoid

• Failure to routinely screen leads to missed diagnosis, especially of hypoactive delirium which is more common than hyperactive delirium 1, 3
• Overreliance on pharmacological interventions without addressing modifiable environmental and iatrogenic factors worsens outcomes 2
• Using continuous lorazepam infusions due to propylene glycol toxicity risk 4
• Abrupt discontinuation of sedatives after prolonged use—taper over several days to prevent withdrawal 4
• Assuming delirium is benign or transient—it is independently associated with increased mortality, prolonged ICU/hospital stay, and long-term cognitive impairment 1, 3

Multicomponent Protocol Implementation

• Use sedation protocols and daily checklists (such as the ABCDEF bundle) to integrate management of pain, agitation, and delirium 1, 2, 5
• The ABCDEF bundle includes: Assessment of pain, Both spontaneous awakening and breathing trials, Choice of sedation, Delirium monitoring, Early mobility, Family engagement 2, 5