Introduction

The most important task in the management of delirium is the identification and treatment of the underlying cause.

Infection

Infection is one of the most common causes of delirium. If infection is suspected, it is essential to commence prompt antibiotic treatment directed at likely organisms, following the collection of appropriate cultures.

However, it is important to remember that it is not the only cause and not present in all cases. UTIs, in particular, are often over-diagnosed [8].

Drug History

Drug history should be reviewed and medications withdrawn, as necessary.

Anticholinergic drugs are particularly implicated in precipitating acute confusional states. Polypharmacy has a role to play in delirium, so consider the indications, potential side-effects and the potential anticholinergic burden [8]. (see next page)

Typical offending medications include [8]:

• Tricyclic antidepressants e.g. amitryptilline
• Antimuscarinics e.g. oxybutynin
• Antihistamines e.g. cetirizine, loratadine, hydroxyzine
• H2 receptor antagonists e.g. ranitidine
• Opioids e.g. codeine
• Benzodiazepines e.g. lorazepam
• Gabapentin
• Theophylline
• Hyoscine

Alcohol

If alcohol abuse, or withdrawal is suspected, remember parenteral thiamine

Biochemical Abnormalities

Biochemical abnormalities (e.g. sodium) do not always occur acutely, and normalisation should proceed cautiously.

The approach to this is multifactorial and includes [9]:

• Identifying and managing each underlying cause or combination of causes
• Effective regular communication with the patient
• Regularly reorientating the patient. Consider involving friends, family and carers to help with this.
• Nursing in a suitable care environment
• Educating caregivers, using written information such as the following leaflet from BGS/RCPsych [9].