Management

• Treatment of the underlying condition: the mainstay of management

  • Consider discontinuing or reducing the dose of causative medications, e.g., anticholinergics. [7][10]

  • See “Etiology” for a detailed list of conditions.

• Supportive care: Clinical manifestations, functional limitations, and associated risks of delirium can persist, requiring admission and supportive care.

• Behavioral emergencies: See “Treatment of agitation in delirium.”

• Patient comfort and symptom control

  • Fever control and pain management (preferably with nonopioid medications)

  • Maintain adequate hydration and nutrition (see “IV fluid therapy”).

  • Evaluate and treat urinary retention or fecal impaction if present.

  • Mobilize the patient as soon as possible.

• Reducing confusion

  • Reorient the patient to time, place, and person

  • Initiate cognitive stimulation therapy to improve cognitive function.

  • See also “Prevention.”

• Prevention of complications

  • Prevention of decubitus ulcers (e.g., mobilization, toilet program)

  • Aspiration precautions

  • Fall prevention

A comprehensive care strategy involving multidisciplinary health providers and family members is preferred to prevent and address complications of delirium.

Agitation should initially be managed with nonpharmacologic strategies.

• Continue supportive care (e.g., reassurance, reorientation).

• Arrange for a family member or sitter to remain with the patient at all times.

• Identify and treat easily reversible causes of agitation: e.g., dehydration, hunger, pain, hypoxia, or urinary retention.

• Use de-escalation techniques: e.g., calm verbal interaction, clear communication. [18]

Avoid physical restraints as much as possible in older patients with delirium, as they can worsen distress and agitation, as well as contribute to preventable injuries.

Medications should be reserved for refractory agitation.

• Sedating medications should be limited to patients with agitation severe enough to pose a risk to themselves or others.

• Consider specialist consultation (e.g., psychiatry, geriatrics) for patients who need continual dosing.

Antipsychotics [7][20]

• Agents

  • Typical antipsychotics: e.g., haloperidol (most commonly used)

  • Atypical antipsychotic options

    • Risperidone

    • Olanzapine

• Adverse effects

  • Sedation

  • Increased risk of falls

  • Extrapyramidal symptoms

  • Lowered seizure threshold

Avoid antipsychotics in patients with underlying alcohol withdrawal or benzodiazepine withdrawal (due to the risk of seizures) and in patients at high risk for QTc prolongation (due to the risk of torsades de pointes). [9]

Benzodiazepines are deliriogenic. Do not treat delirious patients with benzodiazepines unless the delirium is due to alcohol or benzodiazepine withdrawal.