eMedicine Specialties > Emergency Medicine > Neurology
Delirium, Dementia, and Amnesia: Treatment & Medication
Updated: Jan 17, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
- Prehospital care workers involved in the transport of an acutely confused, combative, or delirious patient must ensure the safety of the patient and staff.
- Prior to transport, consider sedation with a benzodiazepine with or without an antipsychotic if unable to control a dangerous patient. Keep in mind that excess sedation may obscure the MMSE in the ED.
- Use physical restraints as needed.
- Provide supplemental oxygen.
- Intubate when the airway is at risk or when the patient is comatose or has a poor gag reflex. Protect the cervical spine in the setting of trauma.
Emergency Department Care
ED physicians caring for the patient with agitation, confusion, delirium, combativeness, or obtundation must ensure the safety of both the patient and the staff while attending to issues of airway protection and immediate recognition and treatment of rapidly reversible problems (eg, hypoxia, hypoglycemia, narcotic overdose).
- Provide supplemental oxygen unless oxygen saturation is above 93% on room air.
- When carbon monoxide poisoning is suspected, ignore the oxygen saturation, obtain a carboxyhemoglobin level, and provide 100% oxygen.
- In cases of airway compromise, coma, or poor gag reflex, the ED physician should have a low threshold for intubation.
- Use rapid sequence intubation (RSI), particularly in the settings of possible head trauma, elevated ICP, or a combative patient. RSI/intubation may be necessary to facilitate imaging studies.
- Treat suspected overdose-induced delirium based on ingestion history and/or toxidromes. Such treatment may range from simple observation and supportive care, activated charcoal, lavage (rarely performed), sedation, specific antidotes to intubation/life support.
- Behavioral control of a patient with delirium who is agitated and combative should be primarily medication-based with physical restraining kept at a minimum and for protection of both the patient and staff (see Medication).
Consultations
Specific cases may require consultation with neurosurgery, neurology, or internal medicine subspecialists (eg, infectious disease, endocrinology, nephrology, gastroenterology, toxicology, psychiatry).
- In the setting of trauma or neurosurgical emergency, notify surgeons early in the workup. When available, a neurosurgeon should be consulted before using mannitol or high-dose steroid therapy.
- The patient's private physician and/or family members are often the best sources of information regarding baseline functioning, prior medical history, and current medications.
- Consult social services for home evaluation and placement issues for patients with dementia.
Medication
Medications typically used in the ED treatment of delirium or acute mental status changes include sedatives, neuroleptics, and antidotes. Other drugs may be useful in treating specific etiologies uncovered in the workup. The medications outlined here are used for acute behavioral changes.
Sedatives
These agents are used to calm acute agitation, to control the behavior of combative patients, and to facilitate procedures.
Lorazepam (Ativan)
Benzodiazepine of choice in ED — safe for a wide variety of acute behavioral disturbances. Can be given PO/SL (for rapid effect in panic attack)/IV/IM and can be mixed in syringe with neuroleptic agent. Sedative hypnotic with short onset of effects and relatively long duration of action. By increasing action of GABA, a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation. When patient needs to be sedated for longer than 24-h period, this medication is excellent. Has longer CNS effect than diazepam and is preferred for seizure control. Easily titrated for acute withdrawal syndromes (eg, alcohol, benzodiazepines, barbiturates) and status seizures when given IV (10 mg or more may be needed in status epilepticus). Two mg of lorazepam approximately equivalent to 5 mg of diazepam. Preferred over neuroleptics for treating toxic effects of hallucinogens, cocaine, stimulants, or PCP.
Adult
0.5-2 mg PO/SL or 2-4 mg IM or 1-2 mg IV
Status epilepticus: 2-10 mg/dose IV, repeat q10-20min; alternative: 2 mg IV initial dose; double dose q10-20min until adequate sedation
Delirium tremens: up to 10-20 mg IV initial dose, repeat prn; severe cases may need >100 mg in first few hours
Pediatric
0.02-0.05 mg/kg PO/IV/IM; not to exceed 4 mg/dose
Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, or MAOIs; alcohol cross-tolerant (alcoholics may require large doses for sedation)
Documented hypersensitivity, preexisting CNS depression, hypotension, narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease
Neuroleptics
These agents have more robust calming effects than benzodiazepines in acutely agitated patients. They act fast when given IV. They can be mixed in the same syringe with lorazepam for rapid chemical restraint (IM/IV). They are easily titrated and long acting.
Haloperidol and droperidol are of the butyrophenone class, which is noted for high potency and low potential for orthostasis. However, they have great potential for extrapyramidal symptoms (EPS)/dystonia.
Caveat: Neuroleptics can mask the signs of withdrawal from alcohol, benzodiazepines, and barbiturates while failing to treat adrenergic and GABA-nergic dysregulation. They do not prevent seizures.
Haloperidol (Haldol)
DOC for severe agitation, acute psychosis, and severe delirium when no contraindications exist. Parenteral dosage form may be admixed in same syringe with 2 mg lorazepam for better anxiolytic effects.
Adult
1-5 mg PO; may be given as liquid for faster onset of action
2-5 mg (5 mg is standard) IV/IM
Elderly or debilitated patients: 0.5-2 mg IV/IM
Pediatric
Severe behavioral disturbance/psychosis: 0.05-0.15 mg/kg/d PO/IV/IM; higher doses may be necessary
May increase tricyclic antidepressant serum concentrations and hypotensive action of antihypertensive agents; phenobarbital or carbamazepine may decrease effects; coadministration with anticholinergics may increase intraocular pressure; encephalopathylike syndrome associated with concurrent lithium
Documented hypersensitivity; narrow-angle glaucoma; bone marrow suppression; severe cardiac or liver disease; severe hypotension; subcortical brain damage; neuroleptic malignant syndrome
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
Severe neurotoxicity that manifests 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 CNS depression or cardiac disease; if history of seizures, benefits must outweigh risks; significant increase in body temperature may indicate intolerance to antipsychotics (discontinue it occurs); use with caution in settings in which seizures may occur (eg, DT, cocaine OD)—neuroleptics can lower seizure threshold
Droperidol (Inapsine)
Some clinicians believe droperidol is DOC for control of severely disturbed and/or violent patient. Somewhat faster acting and more sedating than haloperidol, but more likely to cause hypotension. May exert antipsychotic activity through dopaminergic system. May alter dopamine action in CNS. Parenteral dosage form may be admixed in same syringe with 2 mg lorazepam for better anxiolytic effects.
Now has black-box warning regarding life-threatening torsade de pointes (TdP) (a rhythmic pattern of sinusoidal ventricular complexes that lead to ventricular fibrillation and cardiac arrest), especially in the setting of prolonged QT syndrome. Assessing QT interval via ECG or rhythm strip advised before administering droperidol.
Adult
0.625-5 mg IM/IV (5 mg standard adult dose for chemical restraint)
Pediatric
<2 years: Not established
>2 years: 0.03-0.07 mg/kg IV/IM; may need 0.1-0.15 mg/kg/dose; not to exceed 2.5 mg/dose over 2 min
May increase toxicity of CNS depressants and has additive effects with benzodiazepines
Documented hypersensitivity; neuroleptic malignant syndrome; suspected pheochromocytoma; hypotension; may cause life-threatening torsade de pointes in those with prolonged QT interval
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
Hypovolemic patients may experience hypotension; may decrease pulmonary arterial pressure; 40% of patients develop tardive dyskinesia; elderly may experience high rate of EPS
May cause QT prolongation (delayed recharging of heart between beats) within minutes following injection at doses at or below recommended levels; prolonged QT can cause potentially fatal heart arrhythmia known as torsade de pointes; all patients should undergo a 12-lead ECG prior to administration of drug to determine if QT interval is prolonged (ie, QTc >440 msec for males or 450 msec for females); if QT interval is prolonged, droperidol should not be administered; for patients in whom potential benefit of droperidol treatment is felt to outweigh risks of potentially serious arrhythmias, ECG monitoring should be performed prior to treatment and continued for 2-3 h after completing treatment to monitor for arrhythmias
Atypical antipsychotics
These are newer neuroleptics with a lowered risk of extrapyramidal syndrome (EPS) and improved efficacy for the negative symptoms (eg, withdrawal, apathy) of psychosis because of their enhanced serotonergic activity as compared to older-style neuroleptics. These medications have largely supplanted older neuroleptics for sedation and treatment of psychosis in elderly patients with dementia.
Risperidone (Risperdal)
Often used for sundowning in elderly patients but can increase mortality rate in dementia. Binds to dopamine D2 receptor with 20 times lower affinity than for serotonin 5-HT2 receptor. Improves negative symptoms of psychoses and reduces incidence of EPS. Also may have antidepressant effects, probably because of its serotonin activity.
Adult
1-8 mg/d PO
Initial dosing for delirium or sundowning in elderly persons: 0.25-0.5 mg/d, titrated upwards
Pediatric
Not established
Coadministration with carbamazepine may decrease effects; may inhibit effects of levodopa; clozapine may increase risperidone 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
May cause EPS, orthostatic hypotension, tachycardia, and arrhythmias; increased risk for EPS with doses higher than 10 mg/d
Antidotes
These agents are used when the toxic agent is known and has an antidote or as a coma cocktail in patients who are stuporous or comatose. Includes oxygen, thiamine (100 mg IV/IM), glucose (50 mL of D50W IV push), and naloxone (Narcan; 2-10 mg SC/IM/IV or via ETT). The use of flumazenil (Romazicon) for suspected or known benzodiazepine overdose is controversial. Flumazenil may precipitate refractory seizures in the setting of long-term use or mixed overdose with seizure-inducing agents (eg, TCAs). It may be useful in diagnosis and in avoiding the need for intubation.
Naloxone (Narcan)
Prevents or reverses opioid effects (hypotension, respiratory depression, sedation), possibly by displacing opiates from their receptors.
Adult
0.4-2 mg IV/IM/SC q2-3 min prn; use increments of 0.1-0.2 mg in patients who are opioid dependent; may be given via ETT; may need to repeat dose q20-60min
If no response after administering 10 mg, question diagnosis
Alternatively, when sedation recurs in patients who ingested long-acting narcotics, may be given as a drip; mix 10 mg in 100 mL of diluent, start at 10-20 mL/h, and titrate to effect
Pediatric
0.1 mg/kg IV/IM/SC; repeat q2-3min prn
Decreases analgesic effects of narcotics
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
Caution in cardiovascular disease; may precipitate withdrawal symptoms in patients addicted to opiates; in setting of opioid dependence, naloxone can exacerbate delirium
Glucose supplements
Monosaccharides absorbed from intestine after oral absorption of dextrose results in rapid increase of blood glucose concentrations.
Dextrose
Should be given to any obtunded patient in whom hypoglycemia cannot be rapidly ruled out via bedside testing. Monosaccharide, absorbed from intestine and distributed, stored, and used by tissues. Parenterally injected dextrose is used in patients unable to obtain adequate oral intake; direct oral absorption results in rapid increase of blood glucose concentrations.
Serves to restore blood glucose levels. Each 100 mL of 5% dextrose contains 5 g of dextrose while each 100 mL of 10% dextrose contains 10 g of dextrose.
Effective in small doses; no evidence indicates that it may cause toxicity; concentrated infusions provide higher amounts of glucose and increased caloric intake with minimum fluid volume.
Adult
Able to sustain adequate oral intake: 10-20 g PO; repeat in 10 min if necessary (response should occur in 10 min)
Unable to swallow safely: 10-25 g IV; repeat dose in severe cases; usually given as 1 ampule (50 mL) of D50W (25 gm) repeated X 1 prn (in the absence of accurate blood sugar testing to guide therapy)
Pediatric
0.5-1 g/kg up to 25 g PO--dilute to 12.5% sol <1 year; 25% sol 1-3 years; 50% sol >3 years
Caution when administering parenteral fluids to patients receiving corticosteroids or corticotropin, especially if the solution contains sodium ions
Patients in diabetic coma if blood sugar levels extremely high (avoid in severely dehydrated patients)
Concentrated solution if intraspinal or intracranial hemorrhage present; dehydrated patients diagnosed with delirium tremens, hepatic coma, or glucose-galactose malabsorption syndrome
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
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
May cause nausea, which may also occur with hypoglycemia; IV dextrose solutions may result in dilution of serum electrolyte concentrations, or overhydration when there is fluid overload; caution in patients suffering from congested states or pulmonary edema; hypertonic dextrose given peripherally may cause thrombosis (administer instead through central venous catheter); caution in subclinical diabetes mellitus or carbohydrate intolerance; there is increased risk of inducing significant hyperglycemia or hyperosmolar syndrome if solution is administered rapidly, especially in patients with chronic uremia or carbohydrate intolerance; concentrated solutions should not be administered SC or IM; rates of dextrose infusion higher than 0.5 g/kg/h may produce glycosuria; at infusion rates of 0.8 g/kg/h the incidence of glycosuria is 5%; monitor fluid balance, electrolyte concentrations and acid-base balance closely; dextrose administration may produce vitamin B-complex deficiency
More on Delirium, Dementia, and Amnesia |
| Overview: Delirium, Dementia, and Amnesia |
| Differential Diagnoses & Workup: Delirium, Dementia, and Amnesia |
 Treatment & Medication: Delirium, Dementia, and Amnesia |
| Follow-up: Delirium, Dementia, and Amnesia |
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Further Reading
Keywords
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