Management of Delirium

Initial Assessment and Risk Factor Management

The American College of Critical Care Medicine recommends identifying and addressing reversible causes through comprehensive evaluation, including screening for metabolic derangements, evaluating for infection, reviewing all medications, and assessing for increased intracranial pressure, in patients with delirium 3, 4
Screening for metabolic derangements, such as hypoxia, electrolyte imbalances, hypoglycemia, and dehydration, is crucial in the initial assessment of delirium 5, 6
Evaluating for infection, including urinary tract infection, pneumonia, or other sources, is an essential step in the management of delirium 3, 7
Reviewing all medications and discontinuing or reducing anticholinergics, benzodiazepines, steroids, and opioids that may be contributing to delirium is recommended 8, 6
Assessing for urinary retention or constipation, which are common precipitants in elderly patients, is also important in the initial assessment of delirium 3, 7

The Society of Critical Care Medicine recommends implementing multicomponent non-pharmacological strategies as the primary treatment approach for delirium, including reorientation strategies, optimizing sensory function, promoting sleep hygiene, early mobilization, maintaining adequate hydration and nutrition, and removing unnecessary tubes and catheters 1, 2
Reorientation strategies, such as using clocks, calendars, and familiar objects, and ensuring family presence, can help reduce delirium duration and improve patient outcomes 1, 4
Optimizing sensory function by providing hearing aids and eyeglasses if normally used can also help reduce delirium severity 1, 2
Promoting sleep hygiene by minimizing nighttime noise and light, and clustering care activities, is essential in the management of delirium 1, 8
Early mobilization, encouraging out-of-bed activity as tolerated, can help reduce delirium duration and improve patient outcomes 1, 2
Maintaining adequate hydration and nutrition, and addressing dehydration if present, is crucial in the management of delirium 3, 7
Removing unnecessary tubes and catheters can help reduce delirium severity and improve patient outcomes 6

The American College of Critical Care Medicine recommends reserving antipsychotic medications, such as haloperidol and quetiapine, for severe agitation that poses safety risks to the patient or staff, as routine antipsychotic use does not improve delirium outcomes and may cause harm 1, 2
Haloperidol can be used at a dose of 0.5-1 mg orally or IV every 4-6 hours as needed, with monitoring for QT prolongation and extrapyramidal side effects 4, 8, 6
Quetiapine can be used at a dose of 25-50 mg orally twice daily, and may be preferable for hypoactive delirium due to its sedating properties 3, 9, 8
Olanzapine can be used at a dose of 2.5-5 mg orally or IM daily, and offers sedation benefit in hyperactive delirium 3, 9, 8
Benzodiazepines should be avoided as initial treatment unless the delirium is due to alcohol or benzodiazepine withdrawal, as they can worsen confusion and increase fall risk 9, 8, 6

The American College of Critical Care Medicine recommends using the lowest effective dose for the shortest duration possible, and discontinuing antipsychotics immediately once the acute distressing symptoms resolve 9, 6
Daily delirium assessment using validated tools is essential in monitoring the effectiveness of treatment and reassessing the need for continued pharmacological intervention 5, 9
Supporting caregivers throughout the treatment process, providing education about the condition and expected course, and addressing their concerns and distress, is crucial in the management of delirium 3, 7, 9