Evaluation

Once a patient has been diagnosed with delirium using the CAM, an evaluation to determine the possible underlying causes of the delirium starts with a full history, including a complete medication review, and thorough physical exam.[8] If the history is limited by the patient’s mental state or ability to cooperate, an attempt should be made to question available caregivers about the patient’s health and behavior in the days prior to the presentation.[8]

Possible underlying etiologies of delirium may be remembered using the mnemonic DELIRIUM (see Table 11.5), which can guide the history and physical.

Table 11.5 Delirium mnemonic to guide evaluation

Letter		Examples	Questions for caregiver	Examples of diagnostic studies
D	Drugs/lack of drugs	New or recent medications (e.g., benzodiazepines), alcohol intoxication/withdrawal	Any new or recent medication changes? Any OTC medications? Illicit drugs? Alcohol use?	Urine drug screen, blood alcohol level
			When was his/her last drink of alcohol?
E	Electrolyte abnormalities	High or low glucose, sodium, calcium, urea nitrogen	Has the patient been eating and drinking well? How does s/he access food? Has s/he lost/gained weight?	Chemistry panel, albumin, pre-albumin
L	Lack of sleep/consistent routine	New home, new caregiver	Describe the patient’s routine. Any changes recently?
I	Infections	Pneumonia, UTI, acute cholecystitis, cellulitis, abscess, diverticulitis, appendicitis, gastroenteritis	Has the patient had a fever? Cough? Abdominal pain? Nausea or vomiting?	Lung, skin, and abdominal exams; CBC, urinalysis, urine culture, CT scan, C. difficile assay
R	Reduced sensory input	Vision or hearing loss	Does the patient wear eyeglasses or hearing aids?	Ear exam, eye exam, examination of hearing aids
I	Intracranial	Intracranial hemorrhage, stroke, seizure	Has the patient hit his/her head? Is the patient on a blood thinner?	Neuro exam, head CT, EEG
U	Urinary retention, constipation	Fecal impaction, acute urinary retention	Has the patient had difficulty with urination, bowel movements? When was the last bowel movement?	Abdominal x-ray, bladder scan, rectal exam
M	Major organ dysfunction	Myocardial infarction, kidney failure, respiratory failure with CO₂ retention, mesenteric ischemia	Has the patient complained of chest pain, shortness of breath, abdominal pain, blood in the stools?	Cardiac exam, EKG, CBC, cardiac enzymes, chemistry panel, ABG, hemoccult

Delirium can be the only manifestation of a severe illness, but it usually results from more than one factor.[8] The diagnostic workup should be guided by clinical suspicion coupled with findings on the history and physical exam.[8] Additionally, the patient’s goals of care should be factored into the evaluation and treatment plan. Delirium is often present at the end of life when a palliative or comfort-oriented approach should be considered with the patient and his or her primary decision maker. Patients with delirium often lack capacity to make significant medical decisions so this role may be delegated to the designated decision maker: the person with health care power of attorney or next of kin.

Although many additional studies may be part of the delirium evaluation, some tests to consider are listed in Table 11.6.

Table 11.6 Examples of diagnostic studies in the evaluation of patients with delirium

Test	Diagnoses considered	Threshold for ordering	Comments
Chest x-ray	Pneumonia, pulmonary edema from congestive heart failure	Low	Chest x-ray can rarely be negative early in the course of pneumonia
EKG	Arrhythmia, ischemia	Low	Compare to baseline EKG, if available
Basic metabolic panel	Renal failure, electrolyte abnormalities	Low	Compare renal function to baseline renal function, if available
CBC	Leukocytosis, anemia	Low	Compare to baseline counts, if available
Cardiac enzymes	Ischemia	Low
Urinalysis	Infection	Low	Older women may have abnormal findings that do not indicate infection unless signs and symptoms of infection are present
Urine culture	Infection	Low	Older women may have positive cultures that do not indicate infection unless signs and symptoms of infection are present
Liver function tests	Cholestasis, hepatitis	Intermediate	If fever is present, consider obtaining a right upper quadrant ultrasound to evaluate for acute cholecystitis, which can present atypically in older adults
Abdominal x-ray	Constipation, bowel obstruction	Intermediate	Consider CT if significant concern for intra-abdominal pathology (such as diverticulitis, appendicitis)
Head CT or MRI	Hemorrhage, stroke	Intermediate	Lower threshold in patients who have fallen or are on blood thinners, such as warfarin
EEG	Seizure	Very high	Can help differentiate delirium from other conditions, assess for occult seizures
Urine drug screen	Drug exposure	Low
Blood alcohol level	Intoxication	Low	Only helpful in acute intoxication
Vitamin B12 level	Low B12	Intermediate	Rare to be the cause of acute delirium
Thyroid function tests	Hypothyroidism, hyperthyroidism	Low–intermediate
Arterial blood gas	Hypercarbia, hypoxia	Intermediate
Lumbar puncture	Meningitis	High	Consider in patients with fever and/or headache and/or nuchal rigidity

Management

The management of delirium requires multiple interventions targeting the precipitating and predisposing factors that contributed to the development of delirium.[8] Management should focus on treatments that enhance recovery, maximize function, and improve outcomes while minimizing the negative consequences of delirium.[8] These vary from patient to patient; therefore, certain aspects of the management approach are unique to each patient. For example, a palliative or comfort-oriented approach may be preferred by a patient who is at the end of life. Research on the effectiveness of these individualized management plans is difficult to perform and not available at this time; nonetheless, this approach is recommended until further research results are available.

Precipitating factors, such as infections, dehydration, and constipation, are often easier to address in the management plan than predisposing factors, such as cognitive impairment or hearing impairment, which may be longstanding issues. Nonetheless, even persistent conditions may be improved; for example, providers can address hearing impairment by removing cerumen impaction and providing noise amplifiers or hearing aids.

Pain can be difficult to assess in a patient with delirium since patients may have difficulty self-reporting, and agitation and somnolence from the delirium can mimic under- and over-treatment with opioids. Under-treatment of pain can lead to delirium; therefore, adequate pain control is essential in the management of delirium.[8] A combination of opioid-sparing agents, such as acetaminophen, lidocaine patches, and topical NSAID creams, and approaches, such as heating pads and gentle massage, in addition to opioids may ensure pain relief (see Table 11.3).

All patients with delirium would likely benefit from certain interventions, and this recommendation is extrapolated from the delirium prevention trials[13] and studies on the “delirium room” (DR), also called the “restraint-free room.”[18] This room operates on the principle of “Tolerate, Anticipate, and Don’t Agitate,” and has special features (outlined in Table 11.5) that may lessen the negative outcomes associated with delirium.[18] For example, in the delirium room, physicians try to limit continuous intravenous infusions that tether the patient to an IV pole for prolonged periods, instead using boluses through IVs that are covered by soft gauze.

Physicians should try to untether patients as much as possible to allow for maximum mobility.[18] Restraints, ranging from soft wrist restraints to telemetry leads and intravenous infusions, should be minimized.[18] Bladder catheters should be removed as soon as possible, and patients should be encouraged and, if needed, assisted, to use the toilet.[18]

Another recommendation in the management of delirium is to encourage a normal sleep-wake cycle.[13] Allowing natural daylight and artificial light to keep a room well lit during the day and avoiding nighttime disruptions, such as lab draws and vital sign checks, help patients attend to their natural biological rhythm.

Table 11.7 Features and strategies of the delirium room

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