Delirium

The answer first

Delirium is acute brain failure — an acute, fluctuating disturbance of attention and awareness caused by a medical condition, a drug, or withdrawal. It is the commonest acute neuropsychiatric complication of hospitalisation in older adults, and you will miss it in roughly half of cases.[1]

Three rules run the whole topic. First, acute confusion is delirium until proven otherwise — never blame dementia without documenting an acute change from baseline, anchored to a collateral history. Second, delirium is multifactorial — the patient rarely has a single cause; infection plus dehydration plus an anticholinergic plus urinary retention is the ward classic, so find and treat every precipitant. Third, the management is cause-directed and non-pharmacological — haloperidol is the last resort, reserved for severe distress or danger.[1]

The classic trap: when the exam asks "best initial management of delirium," the answer is almost always identify and treat the cause with multicomponent non-pharmacological care — never haloperidol first. And haloperidol must never touch a patient with Parkinson disease or dementia with Lewy bodies.[1]

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1. [1]Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium Ann Intern Med, 1990.PMID 2240918
2. [2]Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients N Engl J Med, 1999.PMID 10053175
3. [3]Inouye SK Delirium in older persons N Engl J Med, 2006.PMID 16540616
4. [4]Witlox J, Eurelings LSM, de Jonghe JFM, et al. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis JAMA, 2010.PMID 20664045
5. [5]Inouye SK, Westendorp RGJ, Saczynski JS Delirium in elderly people Lancet, 2014.PMID 23992774
6. [6]Bellelli G, Morandi A, Davis DH, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people Age Ageing, 2014.PMID 24590568
7. [7]Page VJ, Ely EW, Gates S, et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial Lancet Respir Med, 2013.PMID 24461612
8. [8]Andersen-Ranberg NC, Poulsen LM, Perner A, et al. Haloperidol for the Treatment of Delirium in ICU Patients N Engl J Med, 2022.PMID 36286254