INTRODUCTION — Delirium is an acute confusional state characterized by an alteration

of consciousness with reduced ability to focus, sustain, or shift attention. This results in a
cognitive or perceptual disturbance that is not better accounted for by a preexisting,
established, or evolving dementia. Delirium develops over a short period of time (usually
hours to days) and tends to fluctuate during the course of the day. Delirium is typically
caused by a medical condition, substance intoxication, or medication side effect.

Delirium is considered by some to be a specific type of confusional state that is

characterized by increased vigilance along with psychomotor and autonomic overactivity
and manifested as agitation, tremulousness, and hallucinations. In this discussion,
however, the term delirium will be used synonymously with acute confusional state and will
include states characterized by somnolence and decreased arousal, so-called hypoactive
delirium. (See "Diagnosis of delirium and confusional states", section on 'Definition and
terminology'.)

The management of delirium is based primarily upon expert consensus and observational
studies, and only a small number of controlled clinical trials, which are difficult to perform in
patients with cognitive impairment. The preponderance of evidence is most compelling for
primary prevention of delirium using non-pharmacologic, multicomponent approaches
targeted broadly at high risk patients [1,2]. Prevention and therapy of delirium are based
on the following principles:

●Avoiding factors known to cause or aggravate delirium, such as multiple

medications, dehydration, immobilization, sensory impairment, and sleep disturbance

●Identifying and treating the underlying acute illness

●Providing supportive and restorative care to prevent further physical and cognitive
decline

●Where appropriate, controlling dangerous and severely disruptive behaviors using

low dose, short acting pharmacologic agents so the first three steps can be
accomplished

The prevention, treatment, and prognosis of delirium will be reviewed here. The definition,
epidemiology, pathogenesis, clinical features, and diagnosis of delirium are discussed
separately. (See "Diagnosis of delirium and confusional states".)

PREVENTION — No intervention or group of interventions reliably prevents delirium;

however, multicomponent, nonpharmacologic interventions that manage many of the
modifiable risk factors appear to reduce the incidence of delirium [3].
Modifying risk factors — A number of factors have been identified as causing or
contributing to delirium in at risk patients. (See "Diagnosis of delirium and confusional
states".)

Examples of interventions designed to mitigate risk factors for delirium include:

●Orientation protocols - Provision of clocks, calendars, windows with outside views,

and verbally re-orienting patients may mitigate confusion that results from
disorientation in unfamiliar environments.

●Cognitive stimulation - Patients with cognitive impairment, in particular, may

benefit from activity such as regular visits from family and friends. At the same time,
sensory overstimulation should be avoided, particularly at night.

●Facilitation of physiologic sleep – Nursing and medical procedures, including the

administration of medications, should be avoided during sleeping hours when
possible. Night-time noise should be reduced. One randomized trial found that the
use of earplugs at night was associated with a lower incidence of confusion in ICU
patients [4].

●Early mobilization and minimized use of physical restraints for patients with
limited mobility - One study in mechanically ventilated, critically ill patients found
that early institution of physical and occupational therapy along with consequent
interruption in use of sedatives, was a lower rate of hospital days with delirium [5].

●Visual and hearing aids for patients with these impairments

●Avoiding and/or monitoring the use of problematic medications - Medications

are often implicated in precipitating delirium, particularly in those already at risk (table
1). In one systematic review, the authors concluded that benzodiazepines should be
avoided in high risk patients, while caution should be used in prescribing opioids,
dihydropyridines, and antihistamines [6].

In one large cluster-randomized control study based in nursing homes,

implementation of a computerized system to identify the use of problematic
medications and trigger a medication review was associated with a lower incidence of
delirium (HR = 0.42) [7].

●Avoiding and treating medical complications – A number of medical conditions

are known to cause or aggravate delirium; these should be managed aggressively
and prevented where possible.

Some studies have focused specifically on early volume repletion for patients with
delirium. While one small study failed to show a benefit for hydration management on
the incidence of delirium in a long-term care setting, the small number of patients (98)
 and short time period of intervention (4 weeks) limited the ability of this study to
demonstrate efficacy [8].

Hypoxemia and infections are other common complications in high-risk settings and
patients. These may contribute to delirium and should be actively monitored for and
treated when identified. An interventional program administered via a geriatric
consultant team that emphasized avoiding medical complications achieved a one-
third reduction in the incidence of delirium among 126 elderly patients undergoing hip
surgery [9].

●Managing pain – Pain may be a significant risk factor for delirium. The use of
nonopioid medications should be used where possible, as these are less likely to
aggravate delirium. Clinicians must balance the benefits of using opioids to treat
significant pain with the potential for an opioid-related delirium.

Studies in patients undergoing surgery suggest that pre-emptive pain treatment may
reduce the incidence of delirium. In one study of 58 older patients, administration
of ketamine (given as a single dose during induction of anesthesia for cardiac
surgery) was associated with a lower rate of postoperative delirium (3 versus 31
percent) [10]. In another study, fascia iliaca compartment block after hip surgery was
associated with a reduced incidence of postoperative delirium in intermediate-risk, but
not in high-risk patients [11]. However, making generalized recommendations from
such studies is difficult, because of the small sample, inconsistent use of
nonpharmacological interventions, and lack of information regarding long-term
outcomes [12].

Certain classes of opioids are probably best avoided in older patients and others
prone to delirium. Meperidine in particular, has been shown in multiple prospective
studies to increase the risk for delirium [13-15].

Cancer patients with terminal delirium and pain may benefit from switching from
shorter-acting opioids to long-acting agents such as methadone [16]. Clinicians
should also consider the possibility that opioid-induced hyperalgesia may cause
breakthrough pain and consider using nonopioid analgesia for pain control.
(See "Prevention and management of side effects in patients receiving opioids for
chronic pain".)

Use of nursing protocols to better manage pain has been demonstrated to reduce the
severity and duration, but not the incidence, of delirium [17].

In one study, a multicomponent intervention used standardized protocols to screen and

control for six risk factors for delirium in 852 hospitalized patients aged 70 or older:
cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment,
and dehydration [18]. Interventions such as those listed above were targeted to the
identified risk factors. This program resulted in a significant reduction in the number of
delirium episodes compared with usual care (62 versus 90) and in the total number of days
with delirium (105 versus 161); there was no effect upon delirium severity or the rate of
recurrence. The investigators have since reported that community hospitals were able to
successfully implement this program when there was a commitment of resources by
hospital leadership and appropriate adaptation of protocols to local needs [19].
Subsequent randomized studies have confirmed that such multicomponent interventions
can reduce the incidence of delirium and/or related complications [20-22].

Medications to prevent delirium — The available evidence does not support the use of
medications to prevent delirium in the acute care or intensive care or postoperative care
settings [23-25]. Investigators continue to study the potential benefit of cholinesterase
inhibitors, antipsychotic agents, and others:

●Cholinesterase inhibitors (e.g., rivastigmine; donepezil) has been proposed as a

means to prevent delirium in selected patients and high risk settings (eg, older
patients with or without dementia, postoperative and post-stroke settings) [26,27].
However, clinical trials have not demonstrated a reduction in the prevalence or
incidence of delirium, and side effects have been greater in patients receiving these
medications [27-31].

●Antipsychotic agents, given prophylactically and in low dose have been studied in
the postoperative setting, and have been associated with inconsistent, and at best,
modest benefits in the incidence, severity, and duration of delirium [32-37]. In one of
these studies, treatment was associated with increased severity and longer duration
of delirium [37]. A 2013 systematic review and meta-analysis of six studies concluded
that such treatment reduced the incidence of delirium, but not the severity or duration;
nor were the incidence of associated adverse events reduced [35]. In this analysis,
second-generation antipsychotics appeared to be more beneficial compared
to haloperidol.

●Gabapentin, in pilot study, reduced the incidence of postoperative delirium, perhaps

by reducing pain and opioid administration [38].

●Melatonin shows promise in the prevention of delirium. The melatonin

agonist, ramelteon, was studied in a randomized trial of 67 older inpatients with
serious medical illness [39]. Compared to placebo, ramelteon 8 mg was associated
with a lower risk of delirium (3 versus 32 percent) despite its lack of effect on sleep
parameters. In another randomized study, administration of low dose melatonin (0.5
mg) in 145 older inpatients was associated with a lower incidence of delirium; long-
term outcomes were not assessed [40]. Finally, in a randomized trial of 222 patients
undergoing hip surgery, preoperative administration of melatonin was associated with
a reduced incidence of postoperative delirium (9 versus 33 percent) [41].
 ●Analgesics to control pain may reduce the incidence or severity of delirium, as
discussed in the section above.

MANAGEMENT — The principles underlying the management of delirium are summarized

in the Algorithm (algorithm 1). The algorithm includes two pathways that are followed
simultaneously: one to manage the behavior disturbance; and another to find and treat the
underlying medical disorder. An important caveat is that the symptoms of delirium can
have a prolonged duration extending many weeks into the post-acute period, after the
underlying causes and risk factors have been corrected.

Treatment of underlying conditions — Virtually any medical condition can precipitate

delirium in a susceptible patient; multiple underlying conditions are often found [42]. When
the underlying acute illness responsible for delirium is identified, specific therapy is
directed toward the medical condition. (See "Acute toxic-metabolic encephalopathy in
adults", section on 'Specific etiologies'.)

The conditions noted most commonly in prospective studies of delirium include:

●Metabolic encephalopathy – These include the following which are discussed in

detail separately. (See "Acute toxic-metabolic encephalopathy in adults".)

•Fluid and electrolyte disturbances

(dehydration, hyponatremia/hypernatremia, hypo/hypercalcemia)

•Infections (sepsis, urinary tract, respiratory tract, skin and soft-tissue)

•Organ failure (uremia, liver failure, hypoxemia/hypercarbia)

•Hypoglycemia

●Drug toxicity - Drug toxicity causes or contributes to approximately 30 percent of all

cases of delirium (table 1) [43]. Clinicians must be aware that delirium can occur even
with "therapeutic" levels of such agents as digoxin or lithium, particularly in at risk
patients.

Certain acute drug poisoning syndromes can be rapidly treated with the appropriate
antidote. (See "General approach to drug poisoning in adults".)

●Withdrawal from alcohol and sedatives - The treatment of alcohol withdrawal is

discussed separately. (See "Management of moderate and severe alcohol withdrawal
syndromes", section on 'Management'.)

While Wernicke encephalopathy is not common, many older hospitalized patients have
biochemical evidence of thiamine deficiency [44]. In addition, chronic alcoholism is often
difficult to detect in this population, and symptoms of persistent alcoholic delirium may be
difficult to distinguish from those of Wernicke encephalopathy [45]. Thiamine
supplementation is inexpensive and virtually risk-free; it should be provided to all
hospitalized patients with evidence of nutritional deficiency. (See "Wernicke
encephalopathy".)

Supportive medical care — The delirious patient is at risk for complications of immobility
and confusion, leading to a high prevalence of irreversible functional decline.

It has long been assumed that the outcome of delirium could be improved by earlier
identification of the disorder and comprehensive intervention to treat underlying causes
and prevent subsequent complications such as immobility, aspiration, and skin breakdown.
Unfortunately, there are few controlled studies. One study found that early identification
and comprehensive geriatric consultation for patients with established delirium had little
impact on length of stay, functional outcome, or survival [46]; another found that
multicomponent interventions shortened the duration of delirium but had no impact on
mortality or nursing home use [47]. Stronger evidence supports the use of these
interdisciplinary efforts for prevention of delirium. (See 'Modifying risk factors' above.)

Nonetheless, an interdisciplinary approach to delirium should focus upon maintaining

adequate hydration and nutrition, enhancing mobility and range of motion, treating pain
and discomfort, preventing skin breakdown, ameliorating incontinence (seen in over half of
delirious patients), and minimizing the risk of aspiration pneumonitis.

This team approach should also include family or other caregivers who may feel frightened
or exhausted; delirium can be the "last straw" for those who have been caring for the
demented. Caregiver resources must be realistically assessed.

Because delirium may require weeks or months to fully resolve, management often
extends into subacute settings [48,49]. Transfers of care to new settings are periods of
particular vulnerability for older patients, and it is important to effectively communicate
information about mental status to the accepting treatment team [50].

Managing agitation — Managing disruptive behavior, particularly agitation and combative

behavior, is a challenging aspect of delirium therapy. This hyperactive delirium is less
common in older patients, and when it occurs, alternates with periods of hypoactive
delirium, which may be less obvious to the clinical staff [51]. Periods of disruptive and
hyperactive behavior place the patient at risk for falls, wandering off, or inadvertently
removing intravenous lines and feeding tubes.

When delirium is manifest by agitation, symptom control is occasionally necessary to

prevent harm or to allow evaluation and treatment. While nonpharmacologic interventions
should be the mainstay of treatment, a cautious trial of psychotropic medication is
warranted in these circumstances. Unfortunately, there are limited data to guide treatment
as the available studies have significant methodologic limitations [24,25].
Nonpharmacologic interventions — Mild confusion and agitation may respond to
interpersonal and environmental manipulations. The hospital environment, characterized
by high ambient noise, poor lighting, lack of windows, frequent room changes, and
restraint use, often contributes to worsening confusion. Special units that address these
concerns have improved the functional outcomes of hospitalization in such frail patients
[52]. Frequent reassurance, touch, and verbal orientation can lessen disruptive behaviors;
family members or other familiar persons are preferred, but professional sitters can also be
used to effect. Delusions and hallucinations should be neither endorsed nor challenged.
Other specific interventions are discussed above. (See 'Modifying risk factors' above.)

Physical restraints should be used only as a last resort, if at all, as they frequently increase
agitation and create additional problems, such as loss of mobility, pressure ulcers,
aspiration, and prolonged delirium. In one study, restraint-use among patients in a medical
inpatient unit was associated with a three-fold increased odds of persistent delirium at time
of hospital discharge [53]. Alternatives to restraint use, such as constant observation
(preferably by someone familiar to the patient such as a family member), may be more
effective.

Neuroleptic medications — When indicated, neuroleptic agents are generally used to

treat severe agitation in the patient with delirium, in part because effective alternatives are
not available. However, there are very limited data that support their use [24,54,55]. In a
randomized, placebo-controlled, study low-dose haloperidol was administered as
prophylactic treatment to older hospitalized patients after hip surgery [32]. As described
above, treatment did not reduce the incidence of delirium, but did reduce the severity and
duration of episodes. One trial randomly assigned 30 individuals admitted to the hospital
with advanced AIDS and subsequent development of delirium to
haloperidol, lorazepam or chlorpromazine [56]. Treatment with either haloperidol or
chlorpromazine (but not lorazepam) resulted in significant improvement in delirium
compared to baseline. Finally, in a randomized study of 101 patients screened for
subsyndromal delirium after cardiac surgery, administration of risperidone (0.5 mg every
12 hours) was associated with a reduced incidence of clinical delirium (34 versus 14
percent) [57].

Because of the longer clinical experience with haloperidol, it remains the standard therapy
in this setting [58]. The newer atypical antipsychotic
agents, quetiapine, risperidone, ziprasidone, and olanzapine have fewer side effects, and
in small studies they appear to have similar efficacy to haloperidol [59-61]. A meta-analysis
of three small studies that compared haloperidol with risperidone and olanzapine found
that the three agents were similarly effective in treating delirium [62]. A small clinical trial
compared escalating doses of quetiapine to placebo as add-on treatment to as-needed
haloperidol in 36 patients in the intensive care unit with delirium [63]. Quetiapine was
associated with a shorter duration of delirium, reduced agitation, and higher rates of
discharge to home after hospitalization. In contrast, a randomized trial comparing
haloperidol, ziprasidone, and placebo in ICU patients found that active treatment did not
improve outcomes when measured by number of days alive without altered mental status
or the incidence of adverse events [55].

Extrapyramidal side effects are higher in patients treated with high-

dose haloperidol (>4.5mg per day), but were similar among patients treated with low-dose
haloperidol, olanzapine, and risperidone [62]. A systematic review of four trials reached
similar conclusions [64]. Sedation can also occur as a side effect of these medications
[63]. Haloperidol is associated with a low frequency of sedation and hypotension and
should also be avoided in patients with underlying parkinsonism, for whom atypical
antipsychotics are preferred. (See "Prognosis and treatment of dementia with Lewy
bodies" and "Management of nonmotor symptoms in Parkinson disease".)

Based on limited evidence, it is recommended that low-dose haloperidol (0.5 to 1.0 mg) be
used to control agitation or psychotic symptoms, up to a maximum dose of 5 mg per day.
Haloperidol can be administered orally, intramuscularly or intravenously. The onset of
action is 30 to 60 minutes after parenteral administration or longer with the oral route. An
immediate response is not expected. Intravenous haloperidol has been associated with
clinically significant QT prolongation requiring additional precautions with its use.
(See "Acquired long QT syndrome: Definitions, causes, and pathophysiology", section on
'Medications'.)

Short term use of antipsychotic agents is advised as these agents have been associated
with a higher risk of mortality and possibly stroke when used in patients with dementia [65].
(See "Management of neuropsychiatric symptoms of dementia".)

Benzodiazepines — Benzodiazepines have a limited role in the treatment of delirium;

they are primarily indicated in cases of sedative drug and alcohol withdrawal or when
neuroleptic drugs are contraindicated. Surveys of practicing clinicians suggest that
benzodiazepines are overprescribed for patients with delirium [66].

(See "Sedative-analgesic medications in critically ill adults: Selection, initiation,

maintenance, and withdrawal".)

Benzodiazepines (eg, lorazepam 0.5 to 1.0 mg) have a more rapid onset of action (five
minutes after parenteral administration) than the antipsychotics, but they can worsen
confusion and sedation [56]. In a prospective study of intensive care unit (ICU) patients,
lorazepam was an independent risk factor for incident delirium, increasing the risk by
approximately 20 percent [67]. A systematic review of benzodiazepine use in delirium
found two studies comparing benzodiazepine versus neuroleptic agents; one study found
no advantage, the other found decreased effectiveness of benzodiazepines compared with
neuroleptics [68]. In two randomized trials of sedative treatment in mechanically ventilated
ICU patients, the benzodiazepine midazolam was associated with significantly more
delirium compared with dexmedetomidine treatment (77 versus 54 percent) [69], while
similar outcomes were observed lorazepam and dexmedetomidine [70].

Cholinesterase inhibitors — Cholinesterase inhibitors do not have a role in the treatment

or symptom management of delirium.

A randomized clinical trial compared rivastigmine to placebo in 104 hospitalized intensive

care patients with delirium who were also prescribed haloperidol. The trial was stopped
early because of higher mortality in the rivastigmine group (22 versus 8 percent) [71].
Median duration of delirium was also longer in the rivastigmine group (5 versus 3 days, p =
0.06). Cholinesterase inhibitors are also not helpful in the prevention of delirium.
(See 'Prevention' above.)

Managing pain — In the appropriate setting (postoperative, post-trauma), the role of pain
as a contributor to delirium and agitation should be considered, and analgesia provided.
As discussed above, therapies to reduce pain should be administered with some caution
as they also have the potential to contribute to delirium. (See 'Modifying risk
factors' above.)

In one randomized study of 53 patients after cardiac surgery, those who

received morphine (5 mg IM) had more rapid improvement of agitation and were less likely
to require additional sedatives than those who were administered haloperidol (5 mg IM)
[72]. Other outcomes were not assessed.

Hypoactive delirium — In general, symptomatic treatment is not used for hypoactive

delirium.

One study suggested that patients with hypoactive delirium have a similar response to
treatment with haloperidol as those who were agitated [73]. Other case reports and one
uncontrolled case series have suggested that treatment with the stimulant
drug methylphenidate may be associated with improved alertness and cognition [74-76].
However, in the absence of stronger evidence, psychostimulants such methylphenidate or
modanifil cannot be recommended for treating hypoactive delirium, because of the
potential risk of precipitating agitation or worsening psychotic symptoms [77].

Terminal delirium — Delirium is common in palliative care settings and causes significant
distress to family members [78]. Underlying causes are often multifactorial, but up to 50
percent of episodes are reversible, particularly when the underlying cause is either
dehydration or medication-related [79,80].

Hyperactive as well as hypoactive presentations of terminal delirium are both common; the
former may require management with neuroleptic medication, usually haloperidol, as
described above [81,82]. (See 'Neuroleptic medications' above.)
In one small case series, methadone appeared to be effective in the treatment of both
refractory pain and terminal delirium when neuroleptic medication was not
[16]. Midazolam sedation has also been described as a therapeutic option in this setting
[83,84]. (See "Overview of managing common non-pain symptoms in palliative care",
section on 'Palliative sedation'.)

Ethical considerations — The treatment of patients with delirium is complicated by the

critical nature of their illness and their impaired capacity to make decisions. The doctrine of
"implied consent" allows the emergency treatment of patients with delirium in order to
stabilize a life-threatening process [85]. However, it is important to document the
assessment of cognitive abilities and decision-making capacity. Current practice leaves
considerable room for improvement. As an example, in a prospective study of 173 medical
and surgical procedures performed in patients with delirium at a university hospital,
investigators found no documented assessments of competency or decision capacity, and
cognitive assessments in only 4 percent of cases [86]. No informed consent was
documented in 19 percent of procedures, and surrogates were used in only 20 percent.

Relying upon implied consent or substituted judgment in cases of delirium introduces other
difficulties since clinicians and proxies do not always make the same decisions as patients.
Every effort should be made to determine what the patient’s own treatment preferences
are, and not assume that decision-making capacity is “all or none”. In some cases, for
example, psychopharmacological treatment of delirium may restore sufficient mental
capacity to allow a discussion of treatment preferences [87]. In addition, since delirium
typically fluctuates in severity, there may also be periods of lucidity in which a discussion
of treatment preferences may take place.

OUTCOMES — Delirium has an enormous impact upon the health of older persons.
Patients with delirium experience prolonged hospitalizations, functional and cognitive
decline, higher mortality and higher risk for institutionalization, even after adjusting for
baseline differences in age, comorbid illness, or dementia [88-95].

Mortality — Mortality associated with delirium is high. A report of pooled results from
several studies estimated the one and six month mortality to be 14 and 22 percent,
respectively, approximately twice that of patients without delirium [96]. These findings were
likely due in part to the presence of concomitant dementia and severe physical illness (eg,
sepsis). However, prospective observational studies that adjusted for dementia and other
potential confounding factors still found that delirium was an independent marker for
mortality at 6 or 12 months after hospitalization [88,97-100].

Studies have also found a relationship between the duration of delirium and mortality
[101,102]. In one study, protracted delirium (ie, persistent symptoms of confusion at six
months) was associated with increased one-year mortality compared with those whose
symptoms had resolved more quickly, regardless of whether or not patients also had
underlying dementia [100].
Persistant cognitive dysfunction — Signs of delirium may persist for 12 months or
longer, particularly in those with underlying dementia [103].

One long-term follow-up study found that after two years, only one-third of patients who
had experienced delirium still lived independently in the community [104]. Another
prospective study of 225 patients after heart surgery, found that those who experienced
delirium were more likely to have persistent drop in MMSE scores over baseline at six
months compared to those who did not suffer delirium (40 versus 24 percent); at 12
months the differences were not quite statistically significant (31 versus 20 percent,
p=0.055) [105]. In a study of 821 patients admitted to medical or surgical intensive care,
the duration of delirium was associated with worse cognitive function at 3 and 12 months.
While only 6 percent had cognitive impairment at baseline, at 12 months, 34 percent had
deficits that were similar to patients with moderate traumatic brain injury [106]. Other
studies have found that patients with delirium are more likely to have long-term cognitive
problems than hospitalized patients who did not suffer from delirium [107]. Thus, although
delirium is considered potentially reversible, impairments may be prolonged and perhaps
permanent, particularly in frail, older patients.

Episodes of delirium during hospitalization adversely affect the course of the disease in
patients with Alzheimer disease (AD). Of 263 participants in the Massachusetts Alzheimer
Disease Research Center patient registry who experienced hospitalization, 56 percent
developed delirium during hospitalization. Although the AD patients with and without
delirium had similar rates of cognitive decline prior to hospitalization, after hospitalization,
deterioration proceeded at twice the rate in the year after hospitalization compared with
patients who did not develop delirium. The higher rate of cognitive decline was evident for
up to five years after the hospital stay [108,109]. Patients with AD who experienced
delirium also had an increased risk of death and institutionalization [94].

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education

materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or
five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topic (see "Patient education: Delirium (confusion) (The Basics)")

●Beyond the Basics topic (see "Patient education: Delirium (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS — Delirium is an acute confusional state
characterized by an alteration of consciousness with reduced ability to focus, sustain, or
shift attention.

●Effective measures to prevent delirium include avoiding where possible, those

factors known to cause or aggravate delirium, orientation protocols, environmental
modification and nonpharmacologic sleep aids, early mobilization and minimizing use
of physical restraints, and visual and hearing aids. (See 'Prevention' above.)

●Prophylactic medications (cholinesterase inhibitors, antipsychotic agents) have not

been conclusively demonstrated to prevent delirium. (See 'Prevention' above.)

●Thiamine supplementation should be considered in all patients with delirium.

(See 'Treatment of underlying conditions' above.)

●When the underlying acute illness responsible for delirium is identified, specific
therapy is directed toward that condition as the most effective means of reversing the
delirium. (See 'Treatment of underlying conditions' above.)

●Physical restraints should be used only as a last resort, if at all, as they frequently
increase agitation and create additional problems, such as loss of mobility, pressure
ulcers, aspiration, and prolonged delirium. (See 'Nonpharmacologic
interventions' above.)

●Frequent reassurance, touch, and verbal orientation from familiar persons can
lessen disruptive behaviors. (See 'Nonpharmacologic interventions' above.)

●A cautious trial of psychotropic medication should be reserved for treatment of

severe agitation or psychosis with the potential for harm. In this setting, we suggest
using low-dose haloperidol (0.5 to 1.0 mg po or IM) (Grade 2C). (See 'Neuroleptic
medications' above.)

•Haloperidol is associated with a low frequency of sedation and hypotension.

-Haloperidol should be avoided in patients with underlying parkinsonism, for

whom atypical antipsychotics (eg, quetiapine) are preferred.

-Short term use of antipsychotic agents is advised.

●Benzodiazepines should be avoided in patients with or at risk for delirium, except in

cases of sedative drug and alcohol withdrawal or when neuroleptic medications are
contraindicated. (See 'Benzodiazepines' above.)

Cholinesterase inhibitors are not effective in preventing or treating the symptoms of

delirium, and often create undesirable side effects. (See 'Cholinesterase
inhibitors' above.)
●Delirium may require weeks or months to fully resolve. Episodes of delirium may
adversely affect the course of the disease in patients with Alzheimer disease.
Delirium appears to be associated with increased short and long-term mortality
(See 'Outcomes' above.)

Use of UpToDate is subject to the Subscription and License Agreement.