The Delphi Delirium Management Algorithms. A practical tool for clinicians, the result of a modified Delphi expert consensus approach

Delirium Delirium is common in hospitalised patients, and there is currently no specific treatment. Identifying and treating underlying somatic causes of delirium is the first priority once delirium is diagnosed. Several international guidelines provide clinicians with an evidence-based approach to screening, diagnosis and symptomatic treatment. However, current guidelines do not offer a structured approach to identification of underlying causes. A panel of 37 internationally recognised delirium experts from diverse medical backgrounds worked together in a modified Delphi approach via an online platform. Consensus was reached after five voting rounds. The final product of this project is a set of three delirium management algorithms (the Delirium Delphi Algorithms), one for ward patients, one for patients after cardiac surgery and one for patients in the intensive care unit.


Algorithm for patients in HOSPITAL WARDS
This algorithm is intended for patients whose screening results indicate possible acute encephalopathy / delirium during admission to a hospital ward.All patients should receive preventive non-pharmacologic measures, regardless of their cognitive state (see Reference Card A).

STEP 1: VERIFY the diagnosis -consider alternative diagnoses
Perform a thorough physical examination for evidence of other acute, potentially life-threatening conditions that may appear similar to acute encephalopathy / delirium.See Reference Card B for guidance.

STEP 2: Identify and treat COMMON underlying causes
Cognitively vulnerable patients (e.g.older adults, patients with cognitive disorders) may develop delirium even from mild physiological disturbances.

Evaluate for infection / sepsis
Screen for common infections, consider blood and other relevant cultures.Older adults and immunocompromised patients with sepsis may not have a high temperature.

Evaluate pain, anxiety, discomfort, immobility and sleep disturbances
Consider undetected pain, bladder retention and constipation (see Reference Card C).Monitor pain with behavioral scales (e.g.Behavioral Pain Scale, BPS) in non-verbal patients.

Review drugs and other intoxicants
-Evaluate all medication and possible interactions.
-Consider intoxication or withdrawal due to nicotine, alcohol and recreational drugs.
-Review sedatives and opioids: these may trigger and prolong delirium.
-Anticholinergic drugs: these may trigger and prolong delirium (see Reference Card D).
-Consider checking medication blood levels.

Evaluate vital signs
Screen for circulatory and respiratory insufficiency.Use an Early Warning Score system to monitor changes in vital signs over time.

STEP 3: Symptomatic treatment
Symptomatic treatment should be individualized, focusing on predominant signs and symptoms.Initate drug treatments only for hyperactive and psychotic features, and if non-pharmacologic measures provide insufficient relief (Reference Card A).
-Psychomotor agitation and anxiety: consider antipsychotics if agitation hinders nursing care or poses a safety risk.Reserve benzodiazepines as a rescue treatment for severe agitation or anxiety, as benzodiazepines may contribute to ongoing delirium.Benzodiazepines may be indicated in patients with alcohol withdrawal.
-Hallucinations and delusions: consider antipsychotics if these symptoms cause distress, anxiety or agitation.

Infection / sepsis
Inspect all wounds and indwelling lines/drains.Consider endocarditis and infections of prosthetics.
Measure CRP, leukocytes and/or procalcitonin, consider blood and other relevant cultures.Older adults and immunocompromised patients with sepsis may not have a high temperature.

Pain, anxiety, discomfort, immobility and sleep disturbances
Consider undetected pain, bladder retention and constipation (see Reference Card C).
Monitor pain with behavioral scales (e.g.Behavioral Pain Scale, BPS) in non-verbal patients.

Drugs and other intoxicants
-Evaluate all medication and possible interactions.
-Consider intoxication or withdrawal due to nicotine, alcohol and recreational drugs.
-Review sedatives and opioids: these may trigger and prolong delirium.
-Anticholinergic drugs: these may trigger and prolong delirium (see Reference Card D).
-Consider checking medication blood levels.
Patients after Cardiac Surgery STEP 3: Symptomatic treatment Symptomatic treatment should be individualized, focusing on predominant signs and symptoms.Initate drug treatments only for hyperactive and psychotic features, and if non-pharmacologic measures provide insufficient relief (Reference Card A).The choice of symptomatic drug treatments depends on the environment.
-Psychomotor agitation and anxiety: consider antipsychotics if agitation hinders nursing care or poses a safety risk.In monitored environments (ICU, HDU, PACU), consider dexmedetomidine or clonidine.Reserve benzodiazepines as a rescue treatment for severe agitation or anxiety, as benzodiazepines may contribute to ongoing delirium.Benzodiazepines may be indicated in patients with alcohol withdrawal.
-Hallucinations and delusions: consider antipsychotics if these symptoms cause distress, anxiety or agitation.

Infection / sepsis
Screen for common infections, consider blood cultures.Consider endocarditis and infections of indwelling catheters, drains or implanted prosthetics.ICU patients with sepsis may have normal or even low temperature.

Airway & respiratory tract
Assess the respiratory tract by physical examination and monitoring parameters.Check arterial blood gas.Consider chest imaging and respiratory cultures.Consider pneumothorax, pulmonary edema, pneumonia and pulmonary embolism.
In mechanically ventilated patients, assess and optimize ventilator settings.Consider increased work of breathing, overexertion, tube obstruction, dyssynchrony, tube discomfort, sinusitis.

Circulatory tract
Assess circulatory system by physical examination and monitoring parameters.Consider low cardiac output (due to arrhythmia, hypovolemia, bleeding, heart failure, tamponade) Consider myocardial ischemia.Check ECG, Hb, lactate, cardiac ischemia markers.

Pain, anxiety, discomfort, immobility and sleep disturbances
Consider undetected pain, bladder retention and constipation (see Reference Card C).
Monitor pain with behavioral scales (e.g.Behavioral Pain Scale, BPS) in non-verbal patients.

Metabolic disorders
Imbalance of sodium, ionized calcium or glucose, metabolic acidosis, kidney dysfunction (uremia) or liver dysfunction (elevated bilirubin, liver enzymes or ammonia) Drugs and other intoxicants -Evaluate all medication and possible interactions.
-Consider intoxication or withdrawal due to nicotine, alcohol and recreational drugs.
-Review sedatives, hypnotics and opioids: these may trigger and prolong delirium.
-Anticholinergic drugs: these may trigger and prolong delirium (see Reference Card D).
-Consider checking medication blood levels.
Patients in Intensive Care Units STEP 3: Symptomatic treatment Symptomatic treatment should be individualized, focusing on predominant signs and symptoms.Initate drug treatments only for hyperactive and psychotic features, and if non-pharmacologic measures provide insufficient relief (Reference Card A).Apply physical restraints only if strictly necessary.
-Psychomotor agitation and anxiety: start with dexmedetomidine or clonidine, titrated to effect.Consider adding antipsychotics if agitation hinders nursing care or poses a safety risk.Reserve benzodiazepines as a rescue treatment for severe agitation or anxiety, as benzodiazepines may contribute to ongoing delirium.
Benzodiazepines may be indicated in patients with alcohol withdrawal.
-Hallucinations and delusions: consider antipsychotics if these symptoms cause distress, anxiety or agitation.
-Somnolence, apathy and psychomotor slowing: reduce sedatives, start mobilization, physical therapy, create a stimulating environment (family visits, music, therapeutic activities).- The Anticholinergic Drug Scale (ADS) is an expert classification of anticholinergic drug effects.This is a list of commonly used drugs with anticholinergic effects.This is not a complete list.
Less potent anticholinergic drugs may still cause relevant adverse effects, for example when combined.For patients with polypharmacy online calculation tools may be helpful to estimate total anticholinergic burden.
Anticholinergic adverse effects include dry mouth and eyes, constipation, tachycardia, urine retention and several neurocognitive effects (forgetfullness, agitation, paranoia and delirium).Risk factors for developing anticholinergic adverse effects are advanced age and dementia.
the patient's cognition and the effect of treatments Assess frequently, using validated scales (RASS, NRS, CAM, etc), according to local guidelines.Are the symptoms resolving with treatment of underlying causes?-Reducesymptomatic drug treatment to lowest effective dose -Continue preventive non-pharmacologic measures (Reference Card A) -Re-assess underlying causes / triggers daily -Consider follow-up for long-term cognitive disorders STEP 5: Search for LESS COMMON underlying causes Acute encephalopathy / delirium may persist despite optimal treatment of the underlying cause.If none of the common underlying causes is present, or delirium persists or worsens under treatment, consider less common underlying causes.These are shown in Reference Card E.
the patient's cognition and the effect of treatments Assess frequently, using validated scales (RASS, NRS, CAM-ICU, etc), according to local guidelines.Are the symptoms resolving with treatment of underlying causes?-Reducesymptomatic drug treatment to lowest effective dose -Continue preventive non-pharmacologic measures (Reference Card A) -Re-assess underlying causes / triggers daily -Consider follow-up for long-term cognitive disorders STEP 5: Search for LESS COMMON underlying causes Acute encephalopathy / delirium may persist despite optimal treatment of the underlying cause.If none of the common underlying causes is present, or delirium persists or worsens under treatment, consider less common underlying causes.These are shown in Reference Card E. examination and consider the differential diagnosis.

NO STEP 4: MONITOR the patient's cognition and the effect of treatments Assess
frequently, using validated scales (RASS, NRS, CAM, etc), according to local guidelines.

see Reference Card A). STEP 1: VERIFY the diagnosis -consider alternative diagnoses Perform
a thorough physical examination for evidence of other acute, potentially life-threatening conditions that may appear similar to acute encephalopathy / delirium.See Reference Card B for guidance.STEP 2: Identify and treat COMMON underlying causesCognitively vulnerable patients (e.g.older adults, patients with cognitive disorders) may develop delirium even from mild physiological disturbances.CirculationAssess circulation by physical examination and vital signs.Consider low cardiac output (due to arrhythmia, hypovolemia, bleeding, heart failure, tamponade) Consider myocardial ischemia.Check ECG, Hb, lactate, cardiac ischemia markers.Airway & respiratory tractAssess for airway obstruction, increased work of breathing, pain worsening with breathing, asymmetrical chest wall movement.Consider pneumothorax, pulmonary edema, pneumonia and pulmonary embolism.Check arterial blood gas.Consider chest imaging and respiratory cultures.
This algorithm is intended for patients whose screening results indicate possible acute encephalopathy / delirium during treatment in the Intensive Care Unit.All patients should receive preventive non-pharmacologic measures, regardless of their cognitive state (see Reference Card A).

and other structural brain pathology
Focal neurological deficits: broad differential diagnosis, including stroke