Managing Delirium: What Clinicians Should Know

Part one of this blog post explored how delirium is a common and significant source of suffering for patients living with serious illness, and their families. It defined delirium, its presentation, risk factors and precipitants, and how to screen for it.

Part two, below, shares strategies that palliative care clinicians can use for managing and preventing delirium in their patients with serious illness, with a focus on behavioral interventions.

The first and most important step in managing delirium is identifying its underlying cause and treating this precipitant directly. While that work-up and management is being pursued, behavioral interventions and psychotropic medications may target specific symptoms associated with delirium.

Behavioral interventions are key in both the management and prevention of delirium. The goal of these measures is to maintain safety, reinforce an appropriate sleep/wake cycle, and reorient the patient to their environment.

While admitted, as much as possible, the patient’s room should be kept free of clutter or unnecessary equipment, which may be distracting or present a fall risk. Removing extraneous leads, IV lines, or other monitoring equipment also helps decrease overstimulation, eliminates potential sources of patient frustration or agitation, and ensures these do not become unintentional restraints that decrease the patient’s mobility. Early mobilization, including engagement with physical therapy, is encouraged.

During the day, the patient’s room should be kept well-lit with room lights on and window blinds or curtains open to allow for entry of natural light. At night, the room should be free of unnecessary stimuli by silencing non-essential alarms, turning off the room lights and TV, and minimizing the amount of noise and light coming in from the hallway. Interruptions in sleep should be avoided by consolidating care and retiming blood draws and vital signs checks so they are not collected overnight, if avoidable.

Patients should be reoriented frequently by visitors and staff, and reassured that they are in a safe place with people who are caring for them. The date and day of the week can be written in large writing in a place clearly visible to the patient. Likewise, a clock with an easy-to-read face can be kept in view to orient the patient to the time of day. Reminding them of the plan for the day may also help orient them to the situation and their surroundings.

Implementing appropriate behavioral interventions is an important first step in managing delirium. For certain patients, medications may be required for additional management.

Medications targeting the underlying conditions driving delirium (e.g., antibiotics for a urinary tract infection) should be started as soon as possible. In general, medications are not used to treat delirium itself but may be used to treat its associated symptoms, including agitation, anxiety, hallucinations, sleep/wake disturbances, etc. Antipsychotic medications may be used to manage agitation, paranoia, hallucinations, or other psychotic symptoms. Melatonin or melatonin receptor agonists may be used to reinforce the patient’s sleep/wake cycle. Alpha-2 agonists are also used to manage agitation, with studies demonstrating the benefit of dexmedetomidine in decreasing the incidence and duration of delirium in intensive care settings. Melatonin or melatonin receptor agonists may be used to reinforce the patient’s sleep/wake cycle.

Hyperactive delirium often requires the management of acute agitation to maintain patient, staff, or visitor safety. For these patients, antipsychotic medications can be helpful. Patients experiencing paranoid thought content may also require antipsychotic agents to manage distress caused by delusions. Haloperidol is a commonly used antipsychotic and has the benefit of being available orally, intravenously, and intramuscularly. These latter two routes of administration may be helpful if, in the setting of acute agitation, the patient is refusing oral medications but maximal efforts to safely verbally redirect the patient have not succeeded. Atypical antipsychotics, including olanzapine, quetiapine, and risperidone, are also frequently used for the management of agitation. Quetiapine and risperidone are available only in oral formulations, while olanzapine may also be administered via intramuscular injection. Some institutions have also begun to administer olanzapine via intravenous injection.

As with hyperactive delirium, using new psychotropic medications in patients experiencing hypoactive delirium should target associated symptoms. The use of antipsychotic agents for the treatment of hypoactive delirium as routine practice is controversial. Most clinicians refrain from administering antipsychotics unless an additional indication warrants their use, including agitation, hallucinations, or delusional thought content, as mentioned earlier. Importantly, it is best to avoid polypharmacy and to avoid starting new deliriogenic agents (e.g., benzodiazepines and anticholinergic agents) to the extent possible. Antipsychotics, especially sedating atypical antipsychotics like olanzapine and quetiapine, may be helpful in reinforcing an appropriate sleep/wake cycle. The evidence supporting the use of psychostimulants in patients with hypoactive delirium is inconclusive and, in general, would not be ideal for patients experiencing co-occurring hallucinations or other psychotic symptoms.

Strategies to prevent delirium and monitor its occurrence have the potential to reduce the incidence of delirium and avoid problematic outcomes. Non-pharmacologic preventative strategies include preserving a patient’s sleep-wake cycle, providing patients with sensory aids including glasses or hearing aids, encouraging re-orientation (either verbally or with communication boards), ensuring appropriate hydration, and facilitating early mobility. A recent systematic review by Hshieh and colleagues found that non-pharmacologic interventions lowered the odds of delirium by 44% among randomized or matched trials.

Improving communication between the patient, their family, and loved ones, and the medical team can be helpful in preventing delirium. This helps to optimize care and decreases patient and family distress related to an episode of delirium if one does occur. Psychoeducation should be provided to describe the nature of delirium, the rationale for diagnostic assessments and behavioral interventions, and what may be expected over time as the patient’s presentation evolves. Before providing psychoeducation, it is best to ask the patient or family their understanding of the patient’s current condition and how much information they feel comfortable hearing in that moment. In the outpatient clinic or as inpatients approach discharge, it is prudent to describe potentially reversible risk factors that could be avoided at home, i.e., taking medications as scheduled, refraining from alcohol use, and avoiding over-the-counter medications with strong anticholinergic effects to avoid increasing a patient’s risk of delirium.

Patients should be encouraged to report cognitive symptoms as they develop if they are able. To this end, efforts should be made to destigmatize cognitive changes, while also stressing the importance of recognizing these symptoms as quickly as possible. Likewise, family and friends should also be advised on the importance of identifying symptoms associated with delirium so that interventions can be implemented as soon as possible. Enlisting the aid of family and loved ones is especially important, given that the cognitive symptoms seen in delirium often impact a patient’s ability to report their own symptoms. In many cases, these collateral contacts spend more time with the patient during their admission and are more familiar with the patient’s baseline mental status and cognition which helps with earlier detection of changes.

Clear communication within the treatment team is also critical in the prevention and management of delirium. During admissions, events from each shift should be clearly documented and communicated to the oncoming team. Delirium often leads to overnight agitation and disrupted sleep/wake cycles in which the patient is awake overnight and asleep or less active during the day. Intermittent, isolated episodes occurring across multiple shifts more clearly make a pattern when a cohesive narrative of events is captured in the record and reports of members across the treatment team are consolidated.

Clinicians can take steps to mitigate the risk of delirium and address it when it happens. As palliative care clinicians, it is our responsibility to address delirium to prevent suffering for our patients and their families.

• A Delirium Whodunit: Understanding the Causes of Delirium, a clinical training game where prescribers gain a better understanding of the causes of delirium and how to identify it in patients
• Reducing Risks for Older Adults, an online clinical training course, which explains the diagnosis of delirium and discusses its impact on the older adult population
• The Challenges That Arise in Decision-Making When Delirium Sets In, a case review that highlights the challenges in assessing the decision-making capacity of a patient with delirium
• How to Reduce Risk for Older Adults with Age-Friendly Care, a blog post that covers the importance of identifying delirium in older adults
• Patient Identification and Assessment, a toolkit used to establish criteria for finding the right patients at the right time and assessing their physical, functional, emotional, social, and spiritual needs
• ACB Calculator, a calculator that can be used to work out the Anticholinergic Burden for your patients

Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.