Prevention and Management of Delirium

Introduction to Delirium Prevention

The use of systemic corticosteroids increases the risk of delirium in vulnerable patients, and it is recommended to minimize their use, utilize the lowest effective dose, and apply preventive non-pharmacological strategies in all patients requiring this treatment, as suggested by the Intensive Care Medicine and Anaesthesia guidelines 1, 2
The Society of Critical Care Medicine recommends considering alternative therapeutic options when possible, to minimize the risk of delirium in vulnerable patients, although the specific guideline is not mentioned in the provided text, the principle is in line with general medical practice 1

Vulnerable populations, including elderly patients, those with prior cognitive impairment or frailty, are at higher risk of delirium when treated with systemic corticosteroids, according to the Anaesthesia guideline 2

Medications such as benzodiazepines, antihistamines (including cyclizine), atropine, and other anticholinergics, as well as hypnotic sedatives, should be avoided as they can worsen delirium, as recommended by the Anaesthesia guideline 2
Antipsychotics like haloperidol may be considered at low doses (0.5-1 mg oral or IV) for severe agitation, but with careful monitoring for side effects, although the specific guideline society is not mentioned, this is a common recommendation in psychiatric care 2
Low-dose antipsychotics such as Haloperidol 0.5-1 mg orally or IV may be considered for severe agitation that poses safety risks despite non-pharmacological interventions, with monitoring for effectiveness and side effects, such as extrapyramidal symptoms and QTc prolongation, while avoiding its use in patients with Parkinson's disease or Lewy body dementia 3, 4, 5, 6
Avoid routine benzodiazepines as first-line treatment, as they may worsen delirium, and consider adding lorazepam for refractory agitation only after therapeutic levels of neuroleptics are achieved, and reduce or eliminate delirium-inducing medications, such as steroids and anticholinergics 4, 7
Anticholinergic medications should be avoided as they can worsen both delirium and urinary retention, and consider opioid rotation if delirium is potentially related to opioid neurotoxicity 7, 4

Systematic evaluation using validated tools such as CAM-ICU or ICDSC should be performed at least once per nursing shift to identify early signs of delirium, as recommended by the JAMA Surgery guideline 6
Non-pharmacological strategies, including ensuring adequate lighting, using orientation aids, maintaining consistent staff, promoting family presence, minimizing noise and disruptions, and removing unnecessary medical equipment, should be the first line of delirium management, although the specific guideline society is not mentioned, these are widely recognized best practices 6
Environmental modifications such as ensuring adequate lighting, using orientation aids, maintaining consistent staff, encouraging family presence, minimizing noise and disruptions, and removing unnecessary medical equipment can help manage delirium, and create a calm, orientation-promoting environment to manage hyperactive delirium 3, 8
Clinical interventions including ensuring adequate hydration, correcting electrolyte abnormalities, optimizing oxygenation, promoting early mobilization, maintaining sleep-wake cycle, and addressing urinary retention can help manage delirium, with supplemental oxygen to maintain SpO2 >94% unless contraindicated 3, 7, 9

In patients with sepsis, hydrocortisone may reduce the incidence of delirium by half, according to the Intensive Care Medicine guideline, although evidence is contradictory 1
Post-surgical patients may benefit from multimodal analgesia to reduce the need for opioids and consider dexmedetomidine as part of pain management to reduce the incidence of postoperative delirium, as suggested by the JAMA Surgery guideline 6
Intermittent catheterization is preferred over indwelling catheterization to reduce the risk of delirium exacerbation in patients with urinary retention, with scheduling every 4-6 hours based on retention volume, and post-void residual volumes should be monitored, as recommended by the American College of Physicians 7
If intermittent catheterization fails, alternative approaches such as a trial of spontaneous voiding with close monitoring or the use of an indwelling catheter with secure catheter fixation and 1:1 observation during the acute delirium phase may be considered, and physical restraints should be avoided as they can worsen delirium 7

Delirium assessment should be performed using validated tools like the Confusion Assessment Method (CAM), evaluating for acute onset, fluctuating course, inattention, and disorganized thinking, with screening at least once per nursing shift 3, 6
Evaluate patients for signs of sepsis and assess for specific UTI symptoms, and perform delirium assessment using validated tools to determine the urgency of intervention and guide management decisions 3
Adjust antibiotics based on culture results when available, and provide appropriate antibiotic therapy for the full prescribed course, as recommended by the American College of Physicians and the Infectious Diseases Society of America 3
Avoid routine treatment of asymptomatic bacteriuria in delirious patients, as evidence shows no improvement in mental status with antibiotic treatment, and it may lead to worse functional outcomes and increased risk of C. difficile infection, as recommended by the American College of Physicians 3, 7