Delirium - APA guidelines 2025

Prevention and treatment of Delirium - APA guideline 2025

This guideline from the American Psychiatric Association (APA),  aims to enhance the quality of care for patients with delirium and prevent its development in at-risk individuals. Delirium is a significant and often unrecognized psychiatric condition, with prevalence rates ranging from 23% in medical inpatient units to 75% in mechanically ventilated ICU patients. It imposes a substantial economic burden, with estimated direct healthcare costs in the U.S. reaching billions annually due to prolonged hospital stays, rehospitalizations, and increased personnel time. Delirium is also associated with significant morbidity and mortality, increasing the risk of death, longer hospital and ICU stays, cognitive dysfunction, functional decline, and psychosocial distress for both patients and caregivers.

The guideline focuses on evidence-based non-pharmacological and pharmacological interventions for adults, grounded in DSM-5-TR diagnostic criteria. It excludes delirium related to alcohol or sedative withdrawal due to its distinct etiology and management. The development process adhered to rigorous standards, utilizing a systematic review of literature through July 2021 and employing the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to rate the strength of guideline statements and evidence. The Guideline Writing Group (GWG) determined recommendations through a modified Delphi method, considering benefits, harms, patient preferences, and the strength of supporting evidence.

Key recommendations emphasize structured assessment for delirium, determining baseline neurocognitive status for accurate interpretation, and a detailed review of predisposing or contributing factors. A comprehensive medication review is crucial to identify and adjust medications that may contribute to delirium. For interventions, the guideline strongly recommends multi-component nonpharmacological approaches for both prevention and management of delirium. Pharmacological interventions should be reserved for severe neuropsychiatric disturbances causing distress or risk of harm, after de-escalation and addressing contributing factors have failed. Specifically, antipsychotic agents are not recommended for preventing delirium or hastening its resolution, though they may be used judiciously for acute agitation. Benzodiazepines are generally discouraged unless there is a specific indication, such as alcohol withdrawal or catatonia, due to potential adverse effects and worsening of delirium. Dexmedetomidine is suggested over other sedating agents for delirium prevention in patients undergoing major surgery or mechanical ventilation in critical care, and for sedating delirious patients on mechanical ventilation. Melatonin and ramelteon are not recommended for delirium prevention or treatment.

Finally, transitions of care are highlighted as critical junctures requiring detailed medication review, reconciliation, and reassessment of medication indications. Follow-up plans should include continued delirium assessments, evaluation of post-delirium consequences (e.g., PTSD, cognitive impairment), and psychoeducation for patients and caregivers.

10 Key Take-Home Points for Clinicians:

1. Implement Routine Structured Delirium Assessments: Use validated tools like CAM, CAM-ICU, 4AT, or Nu-DESC for regular screening of at-risk patients and those exhibiting signs of delirium to improve early detection, especially for hypoactive delirium, which is often missed.
2. Establish Baseline Neurocognitive Status: Accurately determine a patient's pre-hospitalization cognitive function (e.g., using MoCA, IQCODE, AD-8 with family input or prior records) to correctly interpret delirium assessments, diagnose new-onset delirium, and track its resolution.
3. Conduct a Detailed Review of Predisposing/Contributing Factors: Delirium is multifactorial. Systematically identify and address factors such as advanced age, cognitive impairment, infections, organ dysfunction, pain, immobility, and specific medications to tailor treatment effectively.
4. Perform Comprehensive Medication Review and Reconciliation: Critically review all medications (prescribed, OTC, herbal) for agents that can precipitate or worsen delirium, especially in patients with pre-existing cognitive impairment. Deprescribing potentially inappropriate medications is a key strategy.
5. Prioritize Multi-Component Nonpharmacological Interventions: These are the cornerstone of delirium prevention and management. Implement bundles like the ABCDEF Bundle or Hospital Elder Life Program consistently, focusing on early mobility, sleep enhancement, reorientation, vision/hearing aids, and family engagement.
6. Use Pharmacological Interventions Judiciously and for Specific Purposes: Medications, including antipsychotics, should only be used for severe neuropsychiatric disturbances that cause significant patient distress or pose a risk of harm, and only after non-pharmacological methods and addressing underlying factors have failed.
7. Avoid Antipsychotics for Delirium Prevention or to Hasten Resolution: Evidence does not support the routine use of antipsychotics for these purposes. Their use should be time-limited and frequently reassessed for symptom control, not as a primary treatment for delirium itself.
8. Limit Benzodiazepine Use: Generally, avoid benzodiazepines in patients with or at risk for delirium due to increased risk of oversedation, falls, and worsening delirium. Reserve their use for specific indications such as alcohol/sedative withdrawal, catatonia, NMS, or autoimmune encephalitis.
9. Consider Dexmedetomidine in Specific Critical Care/Surgical Contexts: For patients undergoing major surgery or mechanical ventilation in critical care settings, dexmedetomidine is suggested over other sedating agents to prevent delirium and may also be used in delirious mechanically ventilated patients for faster resolution.
10. Ensure Robust Follow-up Planning at Transitions of Care: At every care transition (intra-hospital and discharge), conduct thorough medication reviews to discontinue unnecessary medications (especially those started for delirium). Provide continued delirium assessments, evaluate long-term consequences (cognitive impairment, PTSD), and offer crucial psychoeducation to patients and caregivers.

Link to the guideline document