In general, nonpharmacologic approaches should be used in all delirious patients and usually are successful for symptom management. Pharmacologic approaches should be reserved for patients in whom the delirium symptoms may result in interruption of needed medical therapies (e.g., intubation, intravenous lines) or may endanger the safety of the patient or other persons. No drug is ideal for the treatment of delirium symptoms, however; any choice may cloud the patient's mental status further and obscure efforts to monitor the course of the mental status change. Any drug chosen should be given in the lowest dose for the shortest time possible. Neuroleptics are the preferred agents of treatment, with haloperidol being the most widely used agent. Haloperidol causes less orthostatic hypotension and fewer anticholinergic side effects than thioridazine does and is available in parenteral form; however, it has a higher rate of extrapyramidal side effects and acute dystonias. If parenteral administration is required, intravenous use results in rapid onset of action with a short duration of effect, whereas intramuscular use has a more optimal duration of action and is preferred. The recommended starting dose is 0.5 to 1 mg of haloperidol orally or parenterally, repeated every 30 minutes after the vital signs have been rechecked until sedation has been achieved. The end point should be an awake but manageable patient. The average elderly patient who has not been treated previously with neuroleptics should require a total loading dose of no more than 3 to 5 mg of haloperidol. Subsequently a maintenance dose consisting of half of the loading dose should be administered in divided doses over the next 24 hours, with doses tapered over the next few days as the agitation resolves.

Benzodiazepines are not recommended for the first-line treatment of delirium because of their tendency to cause oversedation and exacerbate the confusional state. They remain the drugs of choice, however, for treatment of withdrawal syndromes from alcohol and sedative drugs.

Nonpharmacologic management techniques recommended for every delirious patient include encouraging the presence of family members, using "sitters" to be orienting influences, or transferring a disruptive patient to a private room or closer to the nurse's station for increased supervision. Interpersonal contact and communication, including verbal reorientation strategies, simple instructions and explanations, and frequent eye contact, are vital. Patients should be involved in their own care and allowed to participate in decision making as much as possible. Eyeglasses and hearing aids may reduce sensory deficits. Mobility, self-care, and independence should be encouraged, and physical restraints should be avoided, if possible, because of their tendency to increase agitation, their questionable efficacy, and their potential to cause injury. Attention must be focused on minimizing the disruptive influences of the hospital environment. Clocks and calendars should be provided to assist with orientation. Room and staff changes should be kept to a minimum. A quiet environment with low-level lighting is optimal for delirious patients. Perhaps the most important intervention is to schedule vital signs, medications, and procedures to allow an uninterrupted period for sleep at night. Nonpharmacologic approaches to relaxation, including music, relaxation tapes, and massage, can be highly effective.