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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.