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1. Antipsychotic Medications

  • Haloperidol

    High-potency antipsychotic medications, such as haloperidol, are the pharmacological treatment of choice for delirium.

    • Haloperidol 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.

  • Droperidol

    • Droperidol may 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

    • Risperidone, 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 available.

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2. Other Interventions for Delirium Caused by Specific Etiologies

  • Benzodiazepines

    • Benzodiazepines 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. of lorazepam.

  • Cholinergics

    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 mechanical ventilation.

  • Opioids

    For patients with delirium in whom pain is an aggravating factor, palliative treatment with an opiate should be considered.

  • Vitamins

    Patients with delirium at risk for B vitamin deficiency, such as alcoholic or malnourished patients, should be given multivitamin replacement.

  • 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.

References

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[The diagnosis and treatment of delirium]. Seishin Shinkeigaku Zasshi 2013;115(11):1150-6.
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