Delirium Diagnosis and Management
Diagnosis and Assessment
- The initial approach to a patient presenting with delirium should include identification of predisposing and precipitating factors through a comprehensive assessment, with particular focus on medication review, infection, metabolic abnormalities, and neurologic causes 1
- Delirium diagnosis should be made by a trained healthcare professional using clinical assessment based on DSM or ICD criteria 2, 3
- When cognitive or behavioral changes suggestive of delirium are present, a formal clinical assessment should be performed to confirm the diagnosis 1, 3
- Distinguish delirium from dementia by assessing onset, course, attention, and consciousness 4
Initial Workup
- Assess for recent changes or fluctuations in cognitive function, behavior, or physical function 1
- Evaluate for sentinel changes including impaired concentration, slow responses, withdrawal, sleep disturbances, hallucinations, confusion, agitation, or mood changes 1
- Perform a complete neurological examination with special attention to level of consciousness, attention, and cognition 4
- Complete blood count to assess for infection 4
- Comprehensive metabolic panel to evaluate electrolytes, renal function, liver function 4
- Urinalysis to rule out urinary tract infection 4
- Blood glucose measurement 4
- Medication levels when appropriate (e.g., digoxin, anticonvulsants) 4
- Consider blood cultures if infection is suspected 1
- Evaluate for hypercalcemia, hypomagnesemia, and SIADH as these are common metabolic causes 2, 3
Evaluation of Common Precipitating Factors
- Review all medications with special attention to vasodilators, diuretics, antipsychotics, sedative/hypnotics, and anticholinergics 4, 6
- Consider opioid-induced neurotoxicity, especially in cancer patients 1, 2
- Evaluate for common infections including urinary tract infection, pneumonia, and sepsis 4, 7, 2
- Assess for electrolyte disturbances, hypoglycemia or hyperglycemia, acid-base disorders, and renal or hepatic dysfunction 2, 5
Management Approach
- Maintain normal sleep-wake cycles 4
- Provide appropriate sensory aids (glasses, hearing aids) 4
- Create a calm, well-lit environment 4
- Pharmacological interventions should be limited to patients with distressing symptoms or safety concerns 8, 6
- Medications should be used at the lowest effective dose and for the shortest time possible 8, 6
- Evidence does not support routine use of haloperidol or risperidone for mild-to-moderate delirium 8, 6
- Benzodiazepines should be reserved for alcohol or benzodiazepine withdrawal delirium or for severe symptomatic distress 8, 6
Special Considerations
- Patients with delirium may have difficulty following commands or remaining still for imaging studies 7
- Coordination with family members and managing physicians may be critical for successful diagnostic imaging 7
- Interprofessional delirium education should be part of a unit- or hospital-wide strategy to improve recognition and management 3