Delirium: Information for clinicians

This information is sourced from Scottish Palliative Care GuidelinesPANG and NICE:

Delirium presents with fluctuating attention.There may be obvious confusion or simply altered levels of consciousness or both. Patients may be aroused and agitated or quiet and withdrawn.

Families find this one of the most distressing symptoms to manage at home.

Delirium is often reversible. However if it presents in the final days of life it may be a multi-factorial terminal delirium/agitation and you must consider if reversal is appropriate at this stage of life.

Red flags

Urgent reversible causes such as sepsis, hypoglycaemia, opioid toxicity and hypercalcaemia must be considered. Alcohol withdrawal is also often forgotten.

Key clinical features  to assess in the community
  • Assessment of consciousness and mental state 
  • Underlying diagnosis as this may help identify the cause
  • Medication review - opioids and steroids commonly cause delirium
  • Physical examination - Temperature/blood pressure/pulse/oxygen saturations. Signs of infection. Check for constipation, urinary retention. Urinalysis and blood glucose.
  • Urgent blood tests for a metabolic cause (FBC, U&E, LFT, TFTs, calcium)
  • Collateral history is important (depression and dementia are differential diagnoses)
  • Review environmental factors contributing to disorientation (e.g. absence of usual hearing/visual aids, noise levels, lighting, access to a clock, disruption of sleep, multiple carer or venue changes)
An initial approach to treatment
  • Stop or reduce dose of offending drugs
  • Haloperidol 2.5mg S/C Stat if required to calm the agitated patient (if they are a risk to self) whilst trying to identify a reversible cause
  • Maintain hydration, oral nutrition and mobility if possible
  • Consider simple interventions such as 1-1 care if possible from staff or family, a calmer environment, lighting, familiar surroundings or objects
  • Consider more specific treatments according to cause - see table below
  • A tool for the identification of delirium may help Confusion Assessment Method (CAM) 
Key Points
  • Do contact the local specialist palliative care team for more specific advice 
  • Lower starting doses of sedatives  in frail elderly
  • Sedation is often more difficult to achieve if there is a history of alcohol or substance misuse
  • Anti-psychotic medicines are usually more helpful than benzodiazepines
  • Levomepromazine is a more sedative anti-psychotic than haloperidol
  • Try non-drug methods to relieve agitation first
Specific treatments according to cause (may be multifactorial)

Cause

Initial approach to treatment

 
Drugs (including opioids, anticholinergics, corticosteroids, benzodiazepines, antidepressants, sedatives)
Reduce the dose or stop offending drug of safe to do so 
Opioid toxicity (myoclonic jerks, slow breathing, recent dose increase) If this is suspected, consider reducing the opioid by 30-50% or an opioid switch 
Drug withdrawal  (alcohol, benzodiazepines, antidepressants, nicotine, opioids) May need sedation if very agitated Nicotine patches can help
Dehydration (recent vomiting or diarrhoea, reduced swallowing) Stop diuretics. May need admission depending on severity and ability to rehydrate orally
Physical causes of discomfort including including pain, nausea, constipation, urinary retention, itching due to opioids or organ failure
  • uncontrolled pain - see Pain
  • full bladder - catheter
  • faecal impaction - laxatives / enema if appropriate
  • nausea - see Nausea & Vomiting
  • pruritus from opioid - consider antihistamine
Metabolic causes(hypoxia, hypercalcaemia, renal and liver failure, hypoglycaemia) Reverse if appropriate - may need admission 
Infection According to cause
Hypoxia (or CO2 retention in COPD) Oxygen may help (or may be too high in cases of COPD)
Cerebral tumour  Dexamethasone
 
Spiritual and psychological distress
Calm reassurance. Exploration of 'unfinished business'. Music may help. Faith input if relevant.

 

Sources

Scottish Palliative Care Guidelines - Delirium

Published 25th August 2020

NICE CKS - Delirium

Published 1st November 2021

PANG Guidelines Quick Guide Agitation and Restlessness

Published 16th October 2016

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