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IV. Formulation and Implementation of a Treatment Plan

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After the diagnosis of delirium is made (see Section II) a treatment plan is developed. The components of the treatment plan and factors that go into a psychiatrist's choice of treatment recommendations are discussed in this section. Although the treatment of delirium involves multiple modalities, certain components are essential and should be implemented with all patients. Other components of treatment may involve a choice between specific therapies, and this choice should be guided by a careful assessment of the patient's clinical condition, etiology, and comorbid conditions.

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A. Psychiatric Management

Psychiatric management is the cornerstone of successful treatment for delirium and should be implemented for all patients with delirium. The goals of psychiatric management are similar for all patients with delirium and involve facilitating the identification and treatment of underlying etiologies, improving patient functioning and comfort, and ensuring the safety of patients and others. The specific elements (see Section III.A) include coordinating care with other clinicians; ensuring that the etiology is identified; ensuring that interventions for acute conditions are initiated; ensuring that disorder-specific treatments are provided; monitoring and ensuring safety; assessing and monitoring psychiatric status; establishing and maintaining supportive therapeutic alliances with patients, families, and other treaters; educating the patient and family regarding the illness; and postdelirium management.

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B. Choice of Specific Environmental and Supportive Interventions

One aspect of the management of delirium involves environmental interventions and cognitive-emotional support provided by nursing, general medical, and psychiatric treaters. The general goals of environmental interventions are to remove factors that exacerbate delirium while providing familiarity and an optimal level of environmental stimulation; the general goals of supportive management include reorientation, reassurance, and education concerning delirium. Specific examples of environmental and supportive interventions are given in Section III.B. These interventions are recommended for all patients with delirium, on the basis of some formal evidence but mainly because of the value observed through clinical experience and the absence of adverse effects.

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C. Choice of Somatic Intervention

The specific features of a patient's clinical condition, the underlying cause(s) of the delirium, and associated conditions may be used by the psychiatrist to determine the choice of specific somatic therapy. Antipsychotic medications are the pharmacologic treatment of choice in most cases of delirium because of their efficacy in the treatment of psychotic symptoms. Haloperidol is most frequently used because of its short half-life, few or no anticholinergic side effects, no active metabolites, and lower likelihood of causing sedation. Haloperidol may be administered orally or intramuscularly, but it appears to cause fewer extrapyramidal side effects when administered intravenously. An optimal dose range for patients with delirium has not been determined. Initial doses of haloperidol in the range of 1–2 mg every 2–4 hours as needed have been used, and even lower starting doses (e.g., 0.25–0.50 mg every 4 hours as needed) are suggested for elderly patients. Titration to higher doses may be required for patients who continue to be agitated. Although total daily intravenous doses in the hundreds of milligrams have been given under closely monitored conditions, much lower doses usually suffice. Continuous intravenous infusions of antipsychotic medications can be used for patients who have required multiple bolus doses of antipsychotic medications. Initiating haloperidol with a bolus dose of 10 mg followed by continuous intravenous infusion of 5–10 mg/hour has been suggested. Droperidol, either alone or followed by haloperidol, can be considered for patients with delirium and acute agitation for whom a more rapid onset of action is required. The ECG should be monitored in patients receiving antipsychotic medications for delirium, and a QTc interval longer than 450 msec or more than 25% over baseline may warrant a cardiology consultation and consideration of discontinuation of the antipsychotic medication. The availability of new antipsychotic medications (risperidone, olanzapine, and quetiapine) with their different side effect profiles has led some physicians to use these agents for the treatment of delirium.

Benzodiazepines can exacerbate symptoms of delirium and, when used alone for general cases of delirium, have been shown to be ineffective. For these reasons, benzodiazepines as monotherapies are reserved for specific types of patients with delirium for which these medications may have particular advantages. For example, benzodiazepines are used most frequently to treat patients with delirium that has been caused by withdrawal of alcohol or benzodiazepines. When a benzodiazepine is used, medications such as lorazepam, which are relatively short-acting and have no active metabolites, are preferable. Combining a benzodiazepine with an antipsychotic medication can be considered for patients with delirium who can only tolerate lower doses of antipsychotic medications or who have prominent anxiety or agitation. Combined treatment can be started with 3 mg i.v. of haloperidol followed immediately by 0.5–1.0 mg i.v. of lorazepam and then adjusted according to the patient's degree of improvement.

Other somatic interventions have been suggested for patients with delirium who have particular clinical conditions or specific underlying etiologies; however, few data are available regarding the efficacy of these interventions in treating delirium. There is some suggestion that cholinergics such as physostigmine and tacrine may be useful in delirium caused by anticholinergic medications. Agitated patients with delirium with hypercatabolic conditions (e.g., hyperdynamic heart failure, adult respiratory distress syndrome, hyperthyroid storm) may require paralysis and mechanical ventilation. For patients with delirium in whom pain is an aggravating factor, palliative treatment with an opiate such as morphine is recommended. ECT may be a treatment consideration in a few cases of delirium due to a specific etiology such as neuroleptic malignant syndrome; any potential benefit of ECT should be weighed against the risks of ECT for patients who are often medically unstable. Any patient with delirium with a reason to be deficient in B vitamins (e.g., alcoholic or malnourished) should be given multivitamin replacement.

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D. Issues of Competency and Consent

Decisions regarding the care of patients with delirium are often complex because of risks associated with treatments, and these decisions frequently have to be made quickly because of the seriousness of the underlying general medical conditions. Unfortunately, delirium intermittently affects consciousness, attention, and cognition and can impair a patient's decisional capacity (i.e., the ability to make decisions as determined by a clinician's evaluation) or competence (i.e., the ability to make decisions as determined by a court of law) (126, 127).

The presence or diagnosis of delirium does not in itself mean that a patient is incompetent or lacks capacity to give informed consent (128). Instead, a determination of decisional capacity or competence to give informed consent involves formal assessment of a patient's understanding about the proposed intervention (including the intervention's risks, benefits, and alternatives) and the consequences of the decisions to be made.

Decision-making guidelines have been suggested for patients with delirium who lack decisional capacity or competence to give informed consent (129). The urgency with which treatment is needed and the risks and benefits of treatments can be used by the treating physician to choose between several alternative courses of action. In medical emergencies requiring prompt intervention, the first alternative is to treat the patient with delirium without informed consent, under the common-law doctrine of implied consent (i.e., that treatment may be provided in medical emergencies without informed consent if it is appropriate treatment that a reasonable person would want). In nonemergency situations, the clinician should obtain input or consent from surrogates. Involving interested family members can be especially helpful for choosing among equally beneficial interventions that involve low or moderate risks. The opinion of a second clinician can be useful for making decisions involving more uncertainty or interventions associated with greater risks. Obtaining the consultation of a hospital's administrator, risk manager, or legal counsel may also provide a means for reassuring family members and the treatment team that reasonable decisions are being made. For decisions that involve significant risks or substantial disagreements involving family members, a court-appointed guardian can be sought if time permits. In more emergent cases, an urgent hearing with a judge may be required. All assessments of a patient's decisional capacity or competence and the reasons for a particular course of action should be documented in the patient's medical record.

References

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