Delirium Medication

  • Author: Kannayiram Alagiakrishnan, MD, MBBS, MHA, MPH; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych (UK)   more...
 
Updated: May 8, 2012
 

Medication Summary

Delirium that causes injury to the patient or others should be treated with medications. The most common medications used are neuroleptics. Benzodiazepines often are used for withdrawal states. Even though case reports showed evidence that cholinesterase inhibitors may play a role in the management of delirium, larger trials and systematic review did not support this use.[26]

A randomized, double-blinded, placebo-controlled, multicenter trial in intensive care unit patients showed rivastigmine did not decrease duration of delirium and increased mortality in these patients. In this trial, the study group had more sicker patients with emergency admissions to the ICU, and this trial had used IV haloperidol, lorazepam, or propofol, in addition to rivastigmine, which might also have contributed to the delirium and increased mortality.[27]

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Neuroleptics

Class Summary

The medication of choice in the treatment of psychotic symptoms. Older neuroleptics such as haloperidol, a high-potency antipsychotic, are useful but have many adverse neurological effects. Newer neuroleptics such as risperidone, olanzapine, and quetiapine relieve symptoms while minimizing adverse effects. Initial doses may need to be higher than maintenance doses. Use lower doses in patients who are elderly. Discontinue these medications as soon as possible. Attempt a trial of tapering the medication once symptoms are in control. Neuroleptics can be associated with adverse neurological effects such as extrapyramidal symptoms, neuroleptic malignant syndrome, and tardive dyskinesia. Doses should be kept as low as possible to minimize adverse effects. Paradoxical and hypersensitivity reactions may occur.

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Haloperidol (Haldol)

 

A butyrophenone high-potency antipsychotic. One of most effective antipsychotics for delirium. High-potency antipsychotic medications also cause less sedation than phenothiazines and reduce risks of exacerbating delirium.

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Risperidone (Risperdal)

 

A newer antipsychotic with fewer extrapyramidal adverse effects than Haldol. Binds to dopamine D2-receptor with 20 times lower affinity than for 5-HT2-receptor. Improves negative symptoms of psychoses and reduces incidence of adverse extrapyramidal effects.

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Short-acting sedatives

Class Summary

Reserved for delirium resulting from seizures or withdrawal from alcohol or sedative hypnotics. Coadministration with neuroleptics is considered only in patients who tolerate lower doses of either medication or have prominent anxiety or agitation. Benzodiazepines are preferred over neuroleptics for treatment of delirium resulting from alcohol or sedative hypnotic withdrawal. They also may be used when unknown substances may have been ingested and may be helpful in delirium from hallucinogen, cocaine, stimulant, or PCP toxicity. Use special precaution when using benzodiazepines because they may cause respiratory depression, especially in patients who are elderly, those with pulmonary problems, or debilitated patients.

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Lorazepam (Ativan)

 

Preferable because it is short acting and has no active metabolites. In addition, can be used in both IM and IV forms. When patient needs to be sedated for longer than 24 h, this medication is excellent. Commonly used prophylactically to prevent delirium tremens.

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Vitamins

Class Summary

Patients with alcoholism and patients with malnutrition are prone to thiamine and vitamin B-12 deficiency, which can cause delirium.

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Thiamine (Thiamilate)

 

For alcohol withdrawal and in cases of Wernicke encephalopathy.

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Cyanocobalamin (Crystamine, Cyomin, Nascobal)

 

Vitamin B-12 deficiency can cause confusion or delirium in patients who are elderly. Deoxyadenosylcobalamin and hydroxocobalamin are active forms of vitamin B-12 in humans. Vitamin B-12 is synthesized by microbes but not by humans or plants. Vitamin B-12 deficiency may result from intrinsic factor deficiency (pernicious anemia), partial or total gastrectomy, or diseases of the distal ileum.

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Contributor Information and Disclosures
Author

Kannayiram Alagiakrishnan, MD, MBBS, MHA, MPH  Associate Professor, Department of Medicine, Division of Geriatric Medicine, University of Alberta Faculty of Medicine and Dentistry, Canada

Kannayiram Alagiakrishnan, MD, MBBS, MHA, MPH is a member of the following medical societies: American College of Physicians and American Geriatrics Society

Disclosure: Nothing to disclose.

Coauthor(s)

Patricia Blanchette, MD  Department Chair and Director, Geriatric Medicine Fellowship Program, Professor of Geriatric Medicine, Geriatric Medicine, John A Burns School of Medicine, University of Hawaii

Patricia Blanchette, MD is a member of the following medical societies: American College of Physicians, American Geriatrics Society, American Medical Association, American Medical Directors Association, Gerontological Society of America, and Hawaii Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mohammed A Memon, MD  Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Sunovion Honoraria Speaking and teaching; Otsuke Grant/research funds reseach; Merck Honoraria Speaking and teaching

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych (UK)  Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of Health Sciences: Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych (UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, American Psychiatric Association, American Society of Clinical Psychopharmacology, and Royal College of Psychiatrists

Disclosure: Nothing to disclose.

References

  1. White S. The neuropathogenesis of delirium. Rev Clin Gerontol. 2002;12:62-67.

  2. Cerejeira J, Batista P, Nogueira V, et al. Low preoperative plasma cholinesterase activity as a risk marker of postoperative delirium in elderly patients. Age Ageing. Sep 2011;40(5):621-6. [Medline].

  3. Shigeta H, Yasui A, Nimura Y, et al. Postoperative delirium and melatonin levels in elderly patients. Am J Surg. Nov 2001;182(5):449-54. [Medline].

  4. de Rooij SE, van Munster BC, Korevaar JC, Levi M. Cytokines and acute phase response in delirium. J Psychosom Res. May 2007;62(5):521-5. [Medline].

  5. Rudolph JL, Ramlawi B, Kuchel GA, et al. Chemokines are associated with delirium after cardiac surgery. J Gerontol A Biol Sci Med Sci. Feb 2008;63(2):184-9. [Medline].

  6. Ebersoldt M, Sharshar T, Annane D. Sepsis-associated delirium. Intensive Care Med. Jun 2007;33(6):941-50. [Medline].

  7. Banks WH. The aged blood- brain barrier: A substrate for CNS disease. Facts, Research and Intervention in Geriatrics. 2000;2000(2):521-530.

  8. Brown LJ, McGrory S, McLaren L, Starr JM, Deary IJ, Maclullich AM. Cognitive visual perceptual deficits in patients with delirium. J Neurol Neurosurg Psychiatry. Jun 2009;80(6):594-9. [Medline].

  9. Limosin F, Loze JY, Boni C, et al. The A9 allele of the dopamine transporter gene increases the risk of visual hallucinations during alcohol withdrawal in alcohol-dependent women. Neurosci Lett. May 20 2004;362(2):91-4. [Medline].

  10. McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium predicts 12-month mortality. Arch Intern Med. Feb 25 2002;162(4):457-63. [Medline].

  11. American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry. May 1999;156(5 Suppl):1-20. [Medline].

  12. Marcantonio ER, Kiely DK, Simon SE, et al. Outcomes of older people admitted to postacute facilities with delirium. J Am Geriatr Soc. Jun 2005;53(6):963-9. [Medline].

  13. Folstein MF, Folstein SE, McGugh PR. "Mini- Mental State".A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. Nov. 1975;12(3):189-98.

  14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association; 2000.

  15. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. Apr 1983;17:37-49.

  16. McAvay GJ, Van Ness PH, Bogardus ST Jr, Zhang Y, Leslie DL, Leo-Summers LS. Depressive symptoms and the risk of incident delirium in older hospitalized adults. J Am Geriatr Soc. May 2007;55(5):684-91. [Medline].

  17. Farrell KR, Ganzini L. Misdiagnosing delirium as depression in medically ill elderly patients. Arch Intern Med. Dec 11-25 1995;155(22):2459-64. [Medline].

  18. Cole M, McCusker J, Dendukuri N, Han L. The prognostic significance of subsyndromal delirium in elderly medical inpatients. J Am Geriatr Soc. Jun 2003;51(6):754-60. [Medline].

  19. Ouimet S, Riker R, Bergeron N, Cossette M, Kavanagh B, Skrobik Y. Subsyndromal delirium in the ICU: evidence for a disease spectrum. Intensive Care Med. Jun 2007;33(6):1007-13. [Medline].

  20. Inouye SK, van Dyck CH, Alessi CA. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. Dec 15 1990;113(12):941-8. [Medline].

  21. Alagiakrishnan K, Marrie T, Rolfson D et al. Gaps in patient care practices to prevent hospital-acquired delirium. Can Fam Physician. 2009;55:e41-6. [Medline].

  22. Rudolph JL, Jones RN, Rasmussen LS, Silverstein JH, Inouye SK, Marcantonio ER. Independent vascular and cognitive risk factors for postoperative delirium. Am J Med. Sep 2007;120(9):807-13. [Medline].

  23. Perry SW. Organic mental disorders caused by HIV: update on early diagnosis and treatment. Am J Psychiatry. Jun 1990;147(6):696-710. [Medline].

  24. Van Muster BC, Korevaar JC, Korse CM , Bonfer JM, Zwinderman AH, DeRooji SE. Serum S 100B in elderly patients with and without delirium. International Journal of Geriatric Psychiatry. 2010;25(3):234-239.

  25. Van Rompaey B, Elseviers M M, Van Drom W, Fromont V, Jorens P G. The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients. Critical Care. 2012;16.

  26. Overshott R, Karim S, Burns A. Cholinesterase inhibitors for delirium. Cochrane Database Syst Rev. Jan 23 2008;CD005317. [Medline].

  27. van Eijk MM, Roes KC, Honing ML, Kuiper MA, Karakus A, van der Jagt M. Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: a multicentre, double-blind, placebo-controlled randomised trial. Lancet. Nov 27 2010;376(9755):1829-37. [Medline].

  28. Maclullich AMJ, Beaglehole A, Hall RA, Meagher DJ. Delirium and long-term cognitive impairment. International Review of Psychiatry. 2009;21(1):30-42.

  29. Alagiakrishnan K, Marrie T, Rolfson D, Coke W, Camicioli R, Duggan D. Simple cognitive testing (Mini-Cog) predicts in-hospital delirium in the elderly. J Am Geriatr Soc. Feb 2007;55(2):314-6. [Medline].

  30. Alagiakrishnan K, Wiens CA. An approach to drug induced delirium in the elderly. Postgrad Med J. Jul 2004;80(945):388-93. [Medline].

  31. Alsop DC, Fearing MA, Johnson K, Sperling R, Fong TG, Inouye SK. The role of neuroimaging in elucidating delirium pathophysiology. J Gerontol A Biol Sci Med Sci. Dec 2006;61(12):1287-93. [Medline].

  32. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med. 2001;27:859-864.

  33. Chan D, Brennan NJ. Delirium: making the diagnosis, improving the prognosis. Geriatrics. Mar 1999;54(3):28-30, 36, 39-42. [Medline].

  34. Day JJ, Bayer AJ, McMahon M. Thiamine status, vitamin supplements and postoperative confusion. Age Ageing. Jan 1988;17(1):29-34. [Medline].

  35. Ely EW, Inouye SK, Bernard GR. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. Dec 5 2001;286(21):2703-10. [Medline].

  36. Hung OL, Lewin NA, Howland MA. Herbal preparations. In: Goldfrank LR, Flomenbaum NE, Lewin NA, et al, eds. Goldfrank's Toxicologic Emergencies. 7th ed. New York: McGraw-Hill; 2002:1129.

  37. Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med. Sep 1994;97(3):278-88. [Medline].

  38. Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. Mar 4 1999;340(9):669-76. [Medline].

  39. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. Mar 20 1996;275(11):852-7. [Medline].

  40. Jones RN, Yang FM, Zhang Y, Kiely DK, Marcantonio ER, Inouye SK. Does educational attainment contribute to risk for delirium? A potential role for cognitive reserve. J Gerontol A Biol Sci Med Sci. Dec 2006;61(12):1307-11. [Medline].

  41. [Best Evidence] Leslie DL, Zhang Y, Holford TR, Bogardus ST, Leo- Summers LS, Inouye SK. Premature death associated with delirium at 1-year follow-up. Arch Intern Med. July 2005;165(14):1657-62. [Medline].

  42. Lipowski ZJ. Delirium (acute confusional states). JAMA. Oct 2 1987;258(13):1789-92. [Medline].

  43. Lipowski ZJ. Delirium in the elderly patient. N Engl J Med. Mar 2 1989;320(9):578-82. [Medline].

  44. Liptzin B, Levkoff SE. An empirical study of delirium subtypes. Br J Psychiatry. Dec 1992;161:843-5. [Medline].

  45. Liptzin B, Levkoff SE, Gottlieb GL. Delirium. J Neuropsychiatry Clin Neurosci. Spring 1993;5(2):154-60. [Medline].

  46. McAvay GJ, Van Ness PH, Bogardus ST Jr, Zhang Y, Leslie DL, Leo-Summers LS. Depressive symptoms and the risk of incident delirium in older hospitalized adults. J Am Geriatr Soc. May 2007;55(5):684-91. [Medline].

  47. O'Keeffe ST, Ni Chonchubhair A. Postoperative delirium in the elderly. Br J Anaesth. Nov 1994;73(5):673-87. [Medline].

  48. O'Keeffee ST. Delirium in the elderly. Age Ageing. Sep 1999;28 Suppl 2:5-8. [Medline].

  49. Obrecht R, Okhomina FO, Scott DF. Value of EEG in acute confusional states. J Neurol Neurosurg Psychiatry. Jan 1979;42(1):75-7. [Medline].

  50. Otter H, Martin J, Bäsell K, von Heymann C, Hein OV, Böllert P. Validity and reliability of the DDS for severity of delirium in the ICU. Neurocrit Care. 2005;2(2):150-8. [Medline].

  51. Ouimet S, Riker R, Bergeon N, Cosette M, Kavanagh B, Skrobik Y. Subsyndromal delirium in the ICU: evidence for a disease spectrum. Intensive Care Med. Apr 3 2007;33(6):1007-1013. [Medline].

  52. Sipahimalani A, Masand PS. Use of risperidone in delirium: case reports. Ann Clin Psychiatry. Jun 1997;9(2):105-7. [Medline].

  53. Trzepacz PT. Delirium. Advances in diagnosis, pathophysiology, and treatment. Psychiatr Clin North Am. Sep 1996;19(3):429-48. [Medline].

 
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Table 1
FeaturesDeliriumDementia
OnsetAcuteInsidious
CourseFluctuatingProgressive
DurationDays to weeksMonths to years
ConsciousnessAlteredClear
AttentionImpairedNormal, except in severe dementia
Psychomotor changesIncreased or decreasedOften normal
ReversibilityUsuallyRarely
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