- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
When delirium is diagnosed or suspected, the underlying causes should be sought. Despite every effort, no cause for delirium can be found in a small percentage of patients. Components of delirium management include supportive therapy and pharmacological management.
- Fluid and nutrition
- These should be given carefully because the patient may be unwilling or physically unable to maintain a balanced intake.
- For the patient suspected of having alcohol toxicity or alcohol withdrawal, therapy should include multivitamins, especially thiamine.
- Environmental modifications
- Reorientation techniques or memory cues such as a calendar, clocks, and family photos may be helpful.
- The environment should be stable, quiet, and well-lighted. Support from a familiar nurse and family should be encouraged.
- Family members and staff should explain proceedings at every opportunity, reinforce orientation, and reassure the patient.
- Sensory deficits should be corrected, if necessary, with eyeglasses and hearing aids.
- Physical restraints should be avoided. Delirious patients may pull out intravenous lines, climb out of bed, and may not be compliant. Perceptual problems lead to agitation, fear, combative behavior, and wandering. Severely delirious patients benefit from constant observation (sitters), which may be cost effective for these patients and help avoid the use of physical restraints.
- These patients should never be left alone or unattended.
Consultations
Psychiatric consultation may be indicated for management of behavioral problems such as agitation or aggressive behavior.
Medication
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.22
Neuroleptics
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.
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.
Adult
Moderate symptomatology: 0.5-2 mg PO bid/tid
Severe symptomatology: 3-5 mg PO bid/tid
Geriatric and debilitated: 0.5-2 mg PO bid/tid; 1-2 mg IM q4-6h
Pediatric
<3 years: Not established
3-12 years: 0.05 mg/kg/d or 0.25-0.5 mg/d PO bid/tid initially and increase by 0.25-0.5 mg q5-7d
Maintenance dose: 0.05-0.15 mg/kg/d PO in 2-3 divided doses; not to exceed 0.15 mg/kg/d
6-12 years: 1-3 mg/dose IM q4-8h, not to exceed 0.15 mg/kg/d; change to PO therapy as soon as possible
>12 years: Administer as in adults
May increase tricyclic antidepressant serum concentrations and hypotensive action of antihypertensive agents; rifampin, phenobarbital, and carbamazepine may decrease effects; coadministration with anticholinergics may increase intraocular pressure; encephalopathiclike syndrome is associated with concurrent administration with lithium; Haldol can potentiate CNS depressant effects of alcohol, opiates, and anesthetics
Documented hypersensitivity, Parkinson disease, severe depression, comatose states
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor for extrapyramidal symptoms (reduce dose if these occur); avoid anticholinergics; severe neurotoxicity manifesting as rigidity or inability to walk or talk may occur in patients with thyrotoxicosis also receiving antipsychotics; if IV/IM, watch for hypotension; caution in diagnosed CNS depression or cardiac disease; if history of seizures, benefits must outweigh risks; significant increase in body temperature may indicate intolerance to antipsychotics (discontinue if it occurs)
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.
Adult
0.5-2 mg PO qd or bid
0.5 mg PO bid for elderly debilitated patients with severe renal or hepatic failure or predisposed to hypotension
Pediatric
Not established
Coadministration with carbamazepine may decrease effects; may inhibit effects of levodopa; SSRIs and clozapine may increase levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Can cause orthostatic hypotension, seizures, hyperprolactinemia, and body temperature regulation abnormalities; has potential for proarrhythmic effects by prolonging QT interval; > 2 mg/d may increase adverse extrapyramidal effects in elderly patients. (Some studies have shown a possible increased risk of stroke.)
Short-acting sedatives
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.
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.
Adult
0.5-2 mg PO/IV/IM; frequent repeat dosing (q2-4h) may be needed in cases of delirium tremens
Pediatric
Not established
Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs
Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma; sleep apnea syndrome; severe respiratory insufficiency
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in limited pulmonary reserve, patients who are elderly, and very ill patients; can cause hypoxic cardiac arrest; caution also needed in patients with myasthenia gravis, organic brain syndrome, or Parkinson disease
Vitamins
Patients with alcoholism and patients with malnutrition are prone to thiamine and vitamin B-12 deficiency, which can cause delirium.
Thiamine hydrochloride (Thiamilate)
For alcohol withdrawal and in cases of Wernicke encephalopathy.
Adult
100 mg IV initially, followed by 50-100 mg/d IV/IM
Pediatric
50 mg IV initially, followed by 10-25 mg/d IV/IM
None reported
Documented hypersensitivity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Sensitivity reactions can occur (intradermal test-dose recommended in suspected sensitivity); deaths have resulted from IV use; sudden onset or worsening of Wernicke encephalopathy may occur following glucose administration in patients who are thiamine-deficient; administer before or together with dextrose-containing fluids in suspected thiamine deficiency
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.
Adult
Maintenance dose: 1000 mcg IM monthly or 500 mcg/wk intranasally or 100 mcg/d PO
Load initially if deficient (100 mcg IM injections for 1 wk, then every wk for 6 mo)
Pediatric
10-50 mcg/d IM for 5-10 d, followed by 100-250 mcg/dose IM q2-4wk
None reported
Documented hypersensitivity; hereditary optic nerve atrophy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Intradermal test dose recommended before parenteral administration (anaphylactic shock and death reported with parenteral administration); hypokalemia and thrombocytosis can occur upon conversion from severe megaloblastic anemia to normal erythropoiesis after cyanocobalamin therapy; monitor serum potassium levels and platelet count; vitamin B-12 therapy can unmask polycythemia vera
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| Differential Diagnoses & Workup: Delirium |
 Treatment & Medication: Delirium |
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Further Reading
Keywords
acute confusional state, acute cognitive dysfunction, toxic metabolic encephalopathy, hyperactive delirium, hypoactive delirium, mixed delirium
