| Evaluation of Delirium |
| History |
Baseline cognitive function and recent changes in mental status (eg, family, staff) Recent changes in condition, new diagnoses, review of systems Review all current medications, including over-the-counter medications and herbal remedies Review any new medications and drug interactions Review alcohol and benzodiazepine use Assess for pain and discomfort (eg, urinary retention, constipation, thirst)
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| Vital signs |
Include temperature, oxygen saturation, fingerstick glucose Postural vital signs as needed
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| Physical and neurological examination |
Search for signs of occult infection, dehydration, acute abdomen, deep vein thrombosis, other acute illness. Assess for sensory impairments. Search for focal neurological changes and meningeal signs
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Targeted laboratory evaluation (selected tests based on clues from history and physical) |
Based on history and physical examination, consider:
Laboratory tests: CBC, electrolytes, calcium, glucose, renal function, liver function, thyroid function, urinalysis, cultures of urine, blood, sputum, drug levels, toxicology screen, ammonia level, vitamin B12 level, cortisol level Arterial blood gas Electrocardiography Chest X-ray Lumbar puncture reserved for evaluation of fever with headache, and meningeal signs, or suspicion of encephalitis
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Targeted neuroimaging (selected patients) |
Assess focal neurological changes, since stroke can present as delirium Suspicion of encephalitis for temporal lobe changes History or signs of head trauma
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| Electroencephalography (selected patients) |
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| Management of Delirium |
| Medication adjustments |
Reduce or remove psychoactive medications (e.g., anticholinergics, sedative- hypnotics, opioids); lower dosages; avoid PRNs Substitute less toxic alternatives Use nonpharmacologic approaches for sleep and anxiety, including music, massage, relaxation techniques
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| Address acute medical issues |
Treat problems identified in work-up (e.g., infection, metabolic disorders) Maintain hydration and nutrition Treat hypoxia
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| Reorientation strategies |
Encourage family involvement; use sitters as needed Address sensory impairment; provide eyeglasses, hearing aids, interpreters
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| Maintain safe mobility |
Avoid use of physical restraints, tethers, and bed alarms, which can increase delirium and agitation Ambulate patient at least 3 times per day; active range-of-motion Encourage self-care and regular communication
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| Normalize sleep-wake cycle |
Daytime: Discourage napping, encourage exposure to bright light Facilitate uninterrupted period for sleep at night Quiet room at night with low level lighting; nonpharmacologic sleep protocol
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| Pharmacologic management (severe agitation or psychosis only) |
Reserve for patients with severe agitation, which will result in interruption of essential medical therapies (e.g., intubation) or severe psychotic symptoms Start low doses and titrate until effect achieved; haloperidol 0.25–0.5 mgs. po/IM BID preferred; atypical antipsychotics close in effectiveness.
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