Acute Brain Failure in the Hospitalized Patient: Mastering the Evidence-Based Prevention and Management of Delirium in Acute Care

In this episode of Hospital Medicine Unplugged, we race through delirium in hospitalized adults—spot it early, fix the causes, deploy bundles, and medicate only when safety’s at stake.

We open with the scale and stakes: delirium hits ~11–42% of general inpatients and up to 87% of older surgical patients, driving falls, longer LOS, institutionalization, cognitive/functional decline, and higher mortality. Hypoactive phenotypes hide in plain sight—look for inattention + fluctuation.

Diagnosis & risk stratification—make screening routine: • Bedside tools: CAM (and Short-CAM/3D-CAM), 4AT, CAM-S (severity). • Method: pair direct interview with chart review; anchor on acute onset, inattention, fluctuating course, ± disorganized thinking or altered consciousness. • Risk factors: age, baseline cognitive impairment, sensory loss, dehydration, sleep deprivation, polypharmacy (+ benzodiazepines/anticholinergics/opioids), infection, metabolic derangements.

Prevention—build the nonpharmacologic bundle (it works): • Multicomponent programs cut incident delirium ~43–53% vs usual care. • Core moves: frequent reorientation & cognitive stimulation; early mobilization; sleep hygiene (cluster care, lights/noise control); hydrate & nourish; vision/hearing optimization (glasses, hearing aids); family engagement; minimize tethers/restraints. • Models: HELP on wards; ABCDEF in ICU (pain/light sedation, delirium monitoring, early mobility, family).

Management—treat delirium like acute brain failure: • First line is always nonpharmacologic + rapid hunt/correct contributors: meds (de-prescribe anticholinergics/benzos when possible), hypoxia, infection, electrolyte/renal/hepatic issues, pain, urinary retention/constipation, withdrawal states. • Environment: daylight cues by day, quiet/dark at night; clocks/calendars; familiar objects; bladder/bowel care. • Mobilize early, restore circadian rhythm, avoid physical restraints whenever possible.

When agitation endangers care or safety: • Antipsychotics (off-label) only for severe agitation: start low-dose haloperidol (e.g., 0.5–1 mg) or consider quetiapine/olanzapine if EPS/QTc risk; use the lowest effective dose for the shortest time. They do not shorten delirium—they just help you get through essential care safely. • Avoid benzodiazepines except for alcohol/benzo withdrawal. • Melatonin/ramelteon: mixed evidence; not routine. • Always re-evaluate daily and de-escalate fast.

Setting-specific pearls: • ICU: screen with CAM-ICU/ICDSC; keep sedation light; dexmedetomidine may beat benzos for ventilated patients; execute ABCDEF. • Post-op: proactive geriatric co-management, opioid-sparing analgesia, regional techniques when appropriate, early mobilization/sleep protection. • Palliative/end-of-life: prioritize comfort and distress reduction; short courses of antipsychotic for severe symptoms after family-aligned goals-of-care discussions.

Prognosis—why urgency matters: • Delirium tracks with higher in-hospital mortality, prolonged stays, discharge to facilities, and long-term cognitive decline; risk rises with duration of delirium. • Many episodes persist to discharge—plan for post-acute screening, rehab, and caregiver education.

Medication pitfalls you don’t want to meet: • Reflex antipsychotic use without addressing causes. • Benzos outside withdrawal (↑ delirium, oversedation). • QT prolongation, EPS, orthostasis/falls—ECG & dose-low/go-slow in older adults.

Research gaps we flag: which bundle elements matter most, pragmatic ways to scale HELP/ABCDEF across diverse hospitals, and safe pharmacologic options that actually shorten delirium.

Bottom line: screen early, fix causes, deploy bundles, and reserve meds for danger—that’s how you prevent falls, shorten stays, and protect cognition.