Treating postoperative delirium should focus on identifying risk factors, as well as underlying conditions, and treating them appropriately. A thorough history and physical should be done first [7]. Postoperative complications, including urinary tract infection, pneumonia, electrolyte disorders, hypotension, hypoxemia, and fluid imbalances can also lead to postoperative delirium and should be ruled out immediately upon the recognition of the patients altered mental status [1, 2]. This can be achieved through checking electrolyte levels, magnesium, phosphate, calcium, arterial blood gas, hemoglobin level, blood cultures, urine culture, urinalysis, and a chest X-ray [6, 7]. The clinician must remember infection presents differently in the elderly population and may not present with leukocytosis and fever, but may present primarily with delerium [7]. Fluid status as well as overall nutritional status should be checked as well and corrected if need be [6]. The above parameters (electrolytes, oxygenation, etc.,) should be optimized upon recognition of postoperative delirium to begin supportive care and encourage expeditious recovery [6].

Medications and polypharmacy also contribute to postoperative delirium [7]. Anticholinergic medications and benzodiazepines should be avoided when possible [2]. Anticholinergic pharmaceuticals, as well as those drugs with anticholinergic side effects, are well known to contribute to postoperative delirium. However, those patients taking benzodiazepines prior to surgery must be kept on them in the postoperative period to prevent benzodiazepine withdrawal, which can also cause delirium [6]. Other medications known to contribute to delirium include: “cimetidine, corticosteroids, diphenhydramine, belladonna, promethazine, warfarin, narcotics, and antiparkinsonian drugs” as well as morphine [7]. These medications should be minimized when possible. Poor postoperative pain control can also contribute to postoperative delirium and should be prevented [6].

Once postoperative delirium has been diagnosed, patient safety becomes paramount. Those patients with hyperactive or mixed delirium will be prone to pull at lines and tubes [7]. Those patients with hypoactive delirium may wander around or even out of their hospital room, unaware of what he/she is doing [7]. Delirious patients are also at risk of falling and may be unable to protect themselves from themselves [7]. These patients should be monitored more closely with one-to-one surveillance or transfer to a higher acuity setting such as a step down unit or ICU [7]. If initial maneuvers to calm the patient fail and the patient continues to be a danger to themselves, restraints and pharmacologic therapy should be instituted [7]. Haldol, the pharmacologic therapy of choice for delirium, may help keep the patient protected from falling or hurting themselves as a result of delirium [2, 6, 7]. Haldol dosing is dependent upon patient placement in the hospital [7]. Those patients in the ICU should receive a loading dose of 2 mg intravenous with another 2 mg given every 15–20 min until the delirium abates [7]. Once controlled, the delirium should be prophylaxed with scheduled doses. Once on the ward, Haldol should be initially dosed at 1–2 mg with 0.25–0.5 mg every 4 hours [7]. The side effects of this medication are extrapyramidal side effects and prolonged QT syndrome. Periodic EKG’s should be monitored while the patient is on this medication [7]. Also, any preoperative metabolic abnormalities, especially those involving sodium, should be corrected prior to surgery if possible [2, 6].