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Based on Practice Guideline for the Treatment
of Patients With Delirium, originally published
in May 1999. A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available.
Conduct a thorough
assessment of the patient's symptoms, including all DSM-IV
criteria for delirium as well as associated features of delirium
(e.g., disturbances in sleep, psychomotor activity, and emotions).
Distinguish among differential diagnostic
possibilities; for patients with features of delirium, the most
common issue is determining whether the patient has dementia, delirium,
Obtain information from medical records,
psychiatric records, medical staff, family, and other sources.
a thorough assessment of the patient's clinical status, including
potential for harm to self or others,
the availability of means for harm to self
or others and the lethality of those means, and
the presence of hallucinations and delusions.
Evaluate comorbid general medical conditions
and past medical history.
delirium require a comprehensive evaluation of their current and
past medical conditions and treatments, including medications, with
special attention paid to those conditions or treatments that might
be contributing to the delirium.
Evaluation by the psychiatrist is frequently
coordinated and conducted jointly with the patient's internist,
neurologist, and other primary care and specialty physicians.
Conduct a thorough history of current
patterns of alcohol and other substance use.
Conduct a thorough assessment of other
current psychiatric disorders or symptoms.
Conduct a thorough assessment of the patient's
past psychiatric history, including
dangerousness to self or others,
previous treatment responses, and
prior alcohol and other substance use.
Conduct a thorough assessment of the patient's
psychosocial history, including
family and interpersonal
premorbid psychosocial, work, living, and
cultural environment; and
availability of family members or other
surrogates capable of helping with decision making for patients
who lack decisional capacity.
Knowledge of the patient's and family's
psychological and social characteristics may be helpful in dealing
with the anxieties and reactions of patients and families.
Throughout the formulation of a treatment plan and the subsequent
course of treatment, the following principles of psychiatric management
should be kept in mind:
Treatment of patients with
delirium frequently requires joint and coordinated management among psychiatrists
and other general medical and specialty physicians.
Review information from the patient's medical and
psychiatric history, family members, and other individuals close
to the patient.
Conduct indicated laboratory and radiological investigations
to determine the underlying cause or causes of the patient's
delirium. The choice of specific tests will be guided by the results
of clinical evaluations and may include those outlined in Table
General physical and neurological examinations
Review of vital signs and anesthesia record
Review of general medical and psychiatric
Careful review of medications and correlation
with behavioral changes
Cognitive tests (e.g., clock face, digit
span, Trail Making tests)
Basic laboratory tests (consider
for all patients with delirium)
electrolytes, glucose, calcium, albumin, blood urea nitrogen (BUN),
creatinine, SGOT, SGPT, bilirubin, alkaline phosphatase, magnesium,
Complete blood count (CBC)
Arterial blood gases or oxygen saturation
Additional laboratory tests (order
as indicated by clinical condition)
and sensitivity (C&S)
Urine drug screen
Blood tests (e.g., VDRL, heavy metal screen,
B12 and folate levels, antinuclear antibody [ANA],
urinary porphyrins, ammonia level, human immunodeficiency virus [HIV],
erythrocyte sedimentation rate [ESR])
Serum levels of medications (e.g., digoxin,
theophylline, phenobarbital, cyclosporine)
Brain computerized tomography (CT) or magnetic
resonance imaging (MRI)
Source. Adapted from Trzepacz PT, Wise MG: "Neuropsychiatric Aspects
of Delirium," in The American Psychiatric Press Textbook
of Neuropsychiatry, Third Edition. Edited by Yudofsky SC, Hales
RE. Washington, DC, American Psychiatric Press, 1997, pp. 447–470.
delirium may have general medical conditions that require urgent
therapeutic intervention, even before an etiology for the delirium
Increased observation and monitoring of
the patient's general medical condition are often necessary,
including frequent monitoring of vital signs, fluid intake and output,
and oxygenation level.
Reversible causes of delirium that are identified should be
promptly treated as noted in Table 2.
Hypoglycemia or delirium of unknown etiology in which
hypoglycemia is suspected
of blood (usually finger stick) to establish diagnosis
Thiamine hydrochloride, 100 mg i.v. (before
50% glucose solution, 50 mL i.v.
Hypoxia or anoxia (e.g., due to pneumonia, obstructive
or restrictive pulmonary disease, cardiac disease, hypotension,
severe anemia, or carbon monoxide poisoning)
Hyperthermia (e.g., temperature above 40.5°C or 105°F)
Severe hypertension (e.g., blood pressure of 260/150
mm Hg, with papilledema)
Alcohol or sedative withdrawal
Thiamine, intravenous glucose, magnesium,
phosphate, and other B vitamins, including folate
hydrochloride, 100 mg i.v., followed by thiamine daily, either intravenously
of offending agent
In severe cases, physostigmine should be
considered unless contraindicated
with delirium for their potential to harm themselves or others.
Harmful behaviors are often inadvertent or are responses to hallucinations
Take appropriate measures to prevent harm
to self or others. Whenever possible, the least restrictive but
effective measures should be employed.
symptoms and behaviors, as they can fluctuate rapidly.
Adjust treatment strategies accordingly.
supportive therapeutic stance with patients.
Establish strong alliances with the patient's
family members, multiple clinicians, and caregivers.
the current delirium, its etiology, and its course should be provided
to patients and tailored to their ability to understand their condition.
Education regarding delirium may also be
extremely beneficial to patients' families, nursing staff,
and other medical clinicians.
reiterate explanations to patient and family about delirium, its
etiology, and its course in order to prevent recurrences.
Provide education regarding the apparent
cause or causes of and risk factors for delirium.
Employ supportive interventions for patients
experiencing distressing postdelirium symptoms.
Employ environmental interventions to reduce
factors that may exacerbate delirium.
These interventions include
lighting to cue day and night,
reducing monotony and overstimulation and
correcting visual and auditory impairments
(e.g., retrieve glasses, hearing aids), and
rendering the patient's environment
less alien by having familiar people and objects present (e.g.,
Reorient the patient to person, place, time,
Reorientation should be provided by all who come into contact
with the patient.
Provide reassurance to patients that the deficits
they are experiencing are common but usually temporary and reversible.
Educate the patient's family and friends
about delirium and reassure them that the patient's deficits
are usually temporary and reversible.
Encourage the patient's family and
friends to reassure and reorient the patient and increase the familiarity
of the patient's environment by increasing staff time with
the patient and by bringing in familiar objects to show the patient.
High-potency antipsychotic medications, such as haloperidol,
are the pharmacological treatment of choice for delirium.
may be administered orally, intramuscularly, or intravenously.
Initial dosages of haloperidol are in the
range of 1 to 2 mg every 2 to 4 hours, with lower starting dosages
for elderly patients (e.g., 0.25 to 0.50 mg every 4 hours).
Continuous intravenous infusion of haloperidol
may be considered for severely ill patients with refractory symptoms
requiring multiple bolus doses. With ECG monitoring, intravenous
haloperidol can be initiated with a bolus dose of up to 10 mg followed
by infusion of up to 5 to 10 mg/hour.
When using haloperidol to treat delirium,
monitor ECG. For QTc intervals greater than 450 msec or greater
than 25% over baseline, consider cardiology consultation
and antipsychotic medication discontinuation.
be considered for acute agitation because of its more rapid onset
of action, greater sedative properties, and shorter half-life.
Droperidol may be administered either alone
or followed by haloperidol.
As with haloperidol, monitor ECG. Droperidol
use has been associated with QTc prolongation, torsades de pointes,
and sudden death.
Newer antipsychotic medications
olanzapine, and quetiapine have been increasingly used to treat
delirium, in part because of their more tolerable side effect profile.
Randomized, double-blind, placebo-controlled
trials of these medications in patients with delirium are not yet
as monotherapy are generally reserved for patients with delirium
caused by seizures or withdrawal from alcohol/sedative-hypnotics.
Benzodiazepines such as lorazepam that are
relatively short acting and have no active metabolites may be preferable.
The combination of a benzodiazepine with
an antipsychotic may be a consideration for patients who can tolerate
only lower doses of antipsychotic medications or who have prominent
anxiety or agitation.
Combined treatment can be initiated with
3 mg i.v. of haloperidol followed immediately by 0.5 to 1.0 mg i.v.
Cholinergic medications, such as physostigmine and donepezil,
may be useful in delirium caused by anticholinergic agents.
Paralysis and ventilation
Agitated patients whose delirium is caused by severe hypercatabolic
conditions such as hyperdynamic heart failure, adult respiratory
distress syndrome, or hyperthyroid storm may require paralysis and
For patients with delirium in whom pain is an aggravating
factor, palliative treatment with an opiate should be considered.
Patients with delirium at risk for B vitamin deficiency, such
as alcoholic or malnourished patients, should be given multivitamin
Electroconvulsive therapy (ECT)
ECT may be a consideration in some cases of delirium caused
by neuroleptic malignant syndrome. The potential benefit of ECT
should be weighed against the risks of such a procedure in patients
who are often medically unstable.