Delirium Management

Introduction to Delirium

• Delirium is characterized by an acute confusional state with disturbed consciousness, cognitive dysfunction, and fluctuating course, according to the American Academy of Neurology and the Society of Critical Care Medicine 1, 2
• The cardinal features of delirium include disturbed level of consciousness, change in cognition, and perceptual disturbance, as defined by the Society of Critical Care Medicine 2
• Delirium can be classified into subtypes, including hyperactive, hypoactive, and mixed, as described by the American Academy of Neurology 1
• The following table compares the features of delirium and dementia:

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Risk Factors and Prevention

• Advanced age significantly increases delirium risk, particularly in patients 78 years or older, according to the American Society of Clinical Oncology 5
• Dehydration may contribute to delirium risk in elderly patients 5
• Polypharmacy is a significant risk factor for delirium, and performing a medication review can help mitigate this risk, as suggested by the American College of Physicians 6
• Pain can be a risk factor for delirium, but it can be difficult to detect in persons with dementia, highlighting the need for careful assessment, as noted by the American College of Physicians 6
• Ensure cognitive stimulation through appropriate activities and conversations, as recommended by the American College of Physicians and the American Geriatrics Society, to prevent delirium in patients, particularly those with pre-existing cognitive impairment or dementia 6, 7
• Implement a non-pharmacological sleep protocol, including reducing noise and light during nighttime hours, scheduling care activities to avoid sleep disruption, and increasing daylight exposure during waking hours, to promote sleep and reduce delirium risk, as suggested by the American Geriatrics Society and the Society of Critical Care Medicine 7, 8
• The following table outlines strategies to prevent delirium:

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Diagnosis and Assessment

• The American Society of Clinical Oncology recommends diagnosing delirium using DSM or ICD criteria by a trained healthcare professional 5
• Hypoactive delirium is often underdiagnosed but is the most prevalent subtype in palliative care, according to the National Comprehensive Cancer Network 10
• Laboratory investigations, including complete blood count, comprehensive metabolic panel, and thyroid function tests, are recommended to identify underlying causes of delirium 5
• The Confusion Assessment Method (CAM) is the most widely used diagnostic instrument for delirium, with proven psychometric properties 3, 5
• The Intensive Care Delirium Screening Checklist (ICDSC) is a tool used for diagnosing delirium in critically ill patients, as recommended by the Society of Critical Care Medicine 11

Management and Treatment

• Identifying and discontinuing delirium-inducing medications, treating infections, metabolic disturbances, or other medical conditions, and managing pain effectively can help address underlying causes of delirium, as recommended by the American College of Physicians 6
• The National Comprehensive Cancer Network recommends identifying and discontinuing delirium-inducing medications, such as steroids and anticholinergics 10
• Reviewing opioids for potential neurotoxicity is recommended, according to the American Society of Clinical Oncology 5
• Antipsychotics should be used cautiously for symptom management, not as routine treatment, according to the Society of Critical Care Medicine 8
• Consider haloperidol as first-line treatment for symptom control in delirium management, as recommended by the National Comprehensive Cancer Network 12
• Benzodiazepines should only be added for agitation refractory to neuroleptics in delirium management, as recommended by the National Comprehensive Cancer Network 12
• For moderate delirium symptoms, oral haloperidol, risperidone, olanzapine, or quetiapine may be used, as recommended by the National Comprehensive Cancer Network 10
• However, recent evidence suggests that haloperidol or risperidone may not be beneficial for mild-to-moderate delirium, according to the American Society of Clinical Oncology 5
• Non-pharmacological interventions, such as environmental modifications, cognitive support, sensory optimization, early mobilization, and sleep-wake cycle regulation, are recommended as first-line treatment for delirium, as stated by the Society of Critical Care Medicine, with a strength of evidence supporting the use of non-pharmacological interventions 7

Outcomes and Prognosis

• 20-50% of delirium episodes can be reversed in patients with advanced cancer who are not imminently dying, according to the American Society of Clinical Oncology 5
• Medication-induced delirium is usually reversible, while delirium due to hypoxic encephalopathy or organ failure is often irreversible, according to the American Society of Clinical Oncology 5
• Delirium is associated with worse outcomes, including increased mortality, longer hospital stays, and higher rates of institutionalization, as reported by the American Academy of Neurology and the American College of Physicians 1, 3
• The annual healthcare costs of delirium in the US are estimated to be $143-$152 billion, according to the American Academy of Neurology 1
• Persistent delirium may indicate poor prognosis in patients with limited life expectancy, according to the National Comprehensive Cancer Network guidelines 12

Education and Staff Training

• Implement formal educational programs for all healthcare staff about delirium recognition and management, using interactive education that engages leadership and employs unit champions, to promote staff awareness and improve delirium care, as recommended by the American Geriatrics Society and the Society of Critical Care Medicine 7, 2
• Establish daily interdisciplinary rounds for delirium assessment and management, to promote collaboration and improve patient outcomes, as suggested by the American Geriatrics Society and the Society of Critical Care Medicine 7, 2
• Providing information about delirium to family members, explaining the fluctuating nature of delirium, and considering debriefing sessions for healthcare teams after challenging cases are recommended, according to the American Society of Clinical Oncology 5