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Throughout the formulation of a treatment plan and the subsequent
course of treatment, the following principles of psychiatric management
should be kept in mind:
Treatment of patients with
delirium frequently requires joint and coordinated management among psychiatrists
and other general medical and specialty physicians.
Review information from the patient's medical and
psychiatric history, family members, and other individuals close
to the patient.
Conduct indicated laboratory and radiological investigations
to determine the underlying cause or causes of the patient's
delirium. The choice of specific tests will be guided by the results
of clinical evaluations and may include those outlined in Table
General physical and neurological examinations
Review of vital signs and anesthesia record
Review of general medical and psychiatric
Careful review of medications and correlation
with behavioral changes
Cognitive tests (e.g., clock face, digit
span, Trail Making tests)
Basic laboratory tests (consider
for all patients with delirium)
electrolytes, glucose, calcium, albumin, blood urea nitrogen (BUN),
creatinine, SGOT, SGPT, bilirubin, alkaline phosphatase, magnesium,
Complete blood count (CBC)
Arterial blood gases or oxygen saturation
Additional laboratory tests (order
as indicated by clinical condition)
and sensitivity (C&S)
Urine drug screen
Blood tests (e.g., VDRL, heavy metal screen,
B12 and folate levels, antinuclear antibody [ANA],
urinary porphyrins, ammonia level, human immunodeficiency virus [HIV],
erythrocyte sedimentation rate [ESR])
Serum levels of medications (e.g., digoxin,
theophylline, phenobarbital, cyclosporine)
Brain computerized tomography (CT) or magnetic
resonance imaging (MRI)
Source. Adapted from Trzepacz PT, Wise MG: "Neuropsychiatric Aspects
of Delirium," in The American Psychiatric Press Textbook
of Neuropsychiatry, Third Edition. Edited by Yudofsky SC, Hales
RE. Washington, DC, American Psychiatric Press, 1997, pp. 447–470.
delirium may have general medical conditions that require urgent
therapeutic intervention, even before an etiology for the delirium
Increased observation and monitoring of
the patient's general medical condition are often necessary,
including frequent monitoring of vital signs, fluid intake and output,
and oxygenation level.
Reversible causes of delirium that are identified should be
promptly treated as noted in Table 2.
Hypoglycemia or delirium of unknown etiology in which
hypoglycemia is suspected
of blood (usually finger stick) to establish diagnosis
Thiamine hydrochloride, 100 mg i.v. (before
50% glucose solution, 50 mL i.v.
Hypoxia or anoxia (e.g., due to pneumonia, obstructive
or restrictive pulmonary disease, cardiac disease, hypotension,
severe anemia, or carbon monoxide poisoning)
Hyperthermia (e.g., temperature above 40.5°C or 105°F)
Severe hypertension (e.g., blood pressure of 260/150
mm Hg, with papilledema)
Alcohol or sedative withdrawal
Thiamine, intravenous glucose, magnesium,
phosphate, and other B vitamins, including folate
hydrochloride, 100 mg i.v., followed by thiamine daily, either intravenously
of offending agent
In severe cases, physostigmine should be
considered unless contraindicated
with delirium for their potential to harm themselves or others.
Harmful behaviors are often inadvertent or are responses to hallucinations
Take appropriate measures to prevent harm
to self or others. Whenever possible, the least restrictive but
effective measures should be employed.
symptoms and behaviors, as they can fluctuate rapidly.
Adjust treatment strategies accordingly.
supportive therapeutic stance with patients.
Establish strong alliances with the patient's
family members, multiple clinicians, and caregivers.
the current delirium, its etiology, and its course should be provided
to patients and tailored to their ability to understand their condition.
Education regarding delirium may also be
extremely beneficial to patients' families, nursing staff,
and other medical clinicians.
reiterate explanations to patient and family about delirium, its
etiology, and its course in order to prevent recurrences.
Provide education regarding the apparent
cause or causes of and risk factors for delirium.
Employ supportive interventions for patients
experiencing distressing postdelirium symptoms.