---
title: Delirium Assessment and Management
description: A comprehensive guide to the clinical assessment and evidence-based management of delirium in the acute care setting.
keywords: [delirium, altered mental status, acute confusion, agitation, hyperactive delirium, hypoactive delirium]
category: clinical
---

## Definition and Epidemiology

Delirium is an acute neuropsychiatric syndrome characterized by a disturbance in attention, awareness, and cognition that develops over a short period of time and tends to fluctuate throughout the day. It is a common and serious condition, affecting up to 50% of hospitalized older adults, and is associated with increased morbidity, mortality, length of stay, and risk of institutionalization.

## Risk Factors and Etiology

Delirium is a multifactorial condition with numerous predisposing and precipitating risk factors. Predisposing factors include advanced age, pre-existing cognitive impairment, sensory impairment, and comorbid medical conditions. Precipitating factors include medications (especially psychoactive drugs), infections, metabolic disturbances, pain, sleep deprivation, and environmental factors such as restraints and lack of orientation cues.

## Clinical Presentation and Subtypes

Delirium typically presents with an acute onset and fluctuating course, with disturbances in attention, awareness, and cognition. Patients may exhibit hyperactive (restless, agitated, and hypervigilant), hypoactive (lethargic, withdrawn, and apathetic), or mixed subtypes. Careful assessment of the patient's mental status, including orientation, memory, language, and level of consciousness, is essential for diagnosis.

## Diagnostic Evaluation

The diagnosis of delirium is primarily clinical, based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. Recommended screening tools include the Confusion Assessment Method (CAM) and the 4 'A's Test (4AT). Laboratory and imaging studies may be necessary to identify underlying etiologies, such as infection, metabolic disturbances, or structural brain abnormalities.

## Management

The management of delirium involves a multifaceted approach targeting the underlying causes, providing supportive care, and minimizing the use of pharmacological interventions.

### Nonpharmacological Interventions
- Identify and treat the underlying cause(s): Conduct a thorough medical evaluation and address any precipitating factors, such as infections, metabolic imbalances, or medication side effects.
- Provide a calm, structured, and familiar environment: Ensure adequate lighting, noise reduction, and the presence of orientation cues (e.g., clocks, calendars).
- Promote sleep and circadian rhythm: Minimize disruptions, provide sleep hygiene measures, and consider melatonin 0.5-5 mg orally at bedtime.
- Encourage early mobility and physical activity: Mobilize the patient as soon as medically feasible to prevent complications.
- Provide cognitive stimulation and reorientation: Engage the patient in simple, familiar activities and provide frequent reorientation.

### Pharmacological Interventions
Pharmacological management should be reserved for patients with severe agitation, aggression, or distress that poses a risk to the patient or others, and should be used cautiously and for the shortest duration possible.

- Antipsychotics: Haloperidol 0.5-2 mg IV/IM every 30 minutes as needed, or olanzapine 2.5-5 mg orally/IM every 4-6 hours as needed. Avoid typical antipsychotics in patients with Parkinson's disease or Lewy body dementia.
- Benzodiazepines: Lorazepam 0.5-2 mg IV/IM every 4-6 hours as needed, only for patients with alcohol or benzodiazepine withdrawal-related delirium.
- Dexmedetomidine: Consider for patients who are unable to tolerate or do not respond to antipsychotics, with an initial infusion of 0.2-0.7 mcg/kg/hr.

### Monitoring and Follow-up
Patients with delirium require close monitoring of vital signs, fluid and electrolyte balance, and cognitive status. Delirium severity should be assessed using validated tools, such as the Delirium Rating Scale-Revised-98 (DRS-R-98) or the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).

## Prognosis and Prevention

Delirium is associated with a poor prognosis, including increased mortality, functional decline, and long-term cognitive impairment. Strategies to prevent delirium include early identification of high-risk patients, optimization of the hospital environment, and implementation of multicomponent, interdisciplinary interventions.

## Conclusion

Delirium is a common and serious condition that requires prompt recognition and a comprehensive, evidence-based approach to management. Clinicians should be familiar with the diagnostic criteria, risk factors, and various treatment modalities to provide high-quality, patient-centered care for individuals with delirium.