Delirium management: treating the underlying cause

Delirium is an acute, fluctuating disturbance of attention and awareness: the confusion is new, and attention changes during the day. It is a sign of an acute underlying problem, so the central step is to find and treat the underlying cause.

Common triggers include infection, dehydration, retention of urine or stool, pain and drugs. Examples of treating the trigger are treating infection, giving fluids and electrolytes for dehydration, and stopping offending medicines.

Speed matters. The outlook (prognosis) often depends on how quickly the cause is identified, and delayed management is associated with a higher risk of later dementia, higher mortality and a longer hospital stay.

Supportive care runs alongside the search for the cause but does not replace it. It includes clear communication, reorientation (telling the person where they are, who they are and what your role is), a calm, well-lit environment and family involvement.

Antipsychotic therapy to control agitation does not treat the cause of delirium. NICE recommends verbal and non-verbal de-escalation (the non-drug measures tried for a distressed person) first. It allows short-term haloperidol, an antipsychotic, usually for a week or less, only if the person is distressed or a risk to themselves or others and de-escalation has failed. Benzodiazepines (drugs with a calming effect) can worsen delirium.

An acute change can suggest delirium on top of dementia. Mild dementia makes delirium more likely, but a clear acute change from baseline points to delirium added to the dementia, and NICE says to manage the delirium first when delirium and dementia are hard to tell apart.