Delirium medical therapy: Difference between revisions

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{{Delirium}}
{{Delirium}}
{{CMG}}; {{AE}} [[User:Vishal Khurana|Vishal Khurana]], M.B.B.S., M.D. [mailto:vishdoc24@gmail.com]; {{PB}}
{{CMG}}; {{AE}} {{Sara.Zand}} {{PB}} ; [[User:Vishal Khurana|Vishal Khurana]], M.B.B.S., M.D. [mailto:vishdoc24@gmail.com]


==Overview==
==Overview==
Treatment of [[delirium]] involves two main strategies: first, treatment of the underlying presumed acute cause or causes, secondly, optimizing [[conditions]] of the [[brain]].  This involves ensuring that the [[patient]] with [[delirium]] has adequate [[oxygenation]], [[hydration]], [[nutrition]], and normal levels of [[metabolites]], so that [[drug ]] effects are minimized, [[constipation]] treated, [[pain ]] treated, and so on.  Detection and management of [[mental]] [[stress]] are also very important.  Therefore, the traditional concept that the treatment of [[delirium ]] is treating the cause is not adequate. Common [[medications]] is used for [[delirium]] treatment include [[antipsychotic]] drugs, [[benzodiazepines]], [[cholinestrase inhibitors]], [[selective -a2 receptor agonist]], [[melatonin]] based [[medications]], [[ketamine]].


==Treatment of Delirium==
==Non-Pharmacological Treatments==
Delirium is not a disease, but a syndrome (i.e. collection of symptoms) indicating dysfunction of the brain, in the same way shortness of breath describes dysfunction of the respiratory system, but does not identify the disorder. Treatment of delirium is achieved by treating the underlying dysfunction cause, or in many cases, the cause'''s''' (plural), as delirium is often multi-factorial.
*[[Delirium]] is not a [[disease]], but a [[syndrome]] (collection of symptoms) indicating dysfunction of the [[brain]].
* Treatment of [[delirium]] is achieved by treating the underlying dysfunction cause.
* Non-pharmacological methods are the first measure in [[delirium]] unless there is severe [[agitation]] that places the [[person]] at risk of harming oneself or others.
* Avoiding unnecessary movement
* Avoidance of inter-and intra‑ward transfers
* Continuity of care from caring staff
* Avoidance of [[physical restraints]]
* Involving family members
* Having recognizable faces at the bedside
* [[Sensory aids]] should be available and working where necessary
* Maintenance or restoration of normal [[sleep]] patterns
* Approach and handle gently
* Avoid sudden and [[irritating noise]] (Pump alarms)
* Careful management of [[ bowel]] and [[bladder]] elimination
* Having a means of [[orientation]] available (such as a [[clock]] and a calendar) may be sufficient in stabilizing the [[situation]]
* Reassurance and explanation to the patient and carer of any procedures or treatment, using short simple sentences
* If this is insufficient, [[verbal]] and non-verbal de-escalation techniques may be required to offer reassurances and calm the person experiencing [[delirium]].<ref>{{Cite web  | last =  | first =  | title = Delirium | url = http://guidance.nice.org.uk/CG103 | publisher =  | date =  | accessdate = }}</ref>
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===The T-A-DA Method (Tolerate, Anticipate, Don't Agitate)===
*T-A-DA is an effective management technique for people with [[delirium]].
* All unnecessary attachments are removed (IVs, [[catheters]], [[ NG tubes]]) which allows for greater [[mobility]].
* [[Patient]] behavior is tolerated, even if it is not considered normal as long as it does not put the [[patient]] or other [[people]] in danger.
* This technique requires that [[patients]] have close supervision to ensure that they remain safe.<ref>{{Cite web  | last =  | first =  | title = Delirium | url = http://guidance.nice.org.uk/CG103 | publisher =  | date =  | accessdate = }}</ref> <ref>{{Cite web  | last =  | first =  | title = Matching the Environment to Patients with Delirium: Lessons Learned from the Delirium Room, a Restraint&#x2010;Free Environment for Older Hospitalized Adults with Delirium - Flaherty -2011 - Journal of the American Geriatrics Society - Wiley Online Library | url = http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2011.03678.x/abstract;jsessionid=AF673522CC21621BCB46B52E7E1ED850.f03t04 | publisher =  | date =  | accessdate = }}</ref>
*[[Patient]] behavior is anticipated so care givers can plan required care.
* [[Patients]] are treated to reduce [[agitation]].
* Reducing [[agitation ]] may mean that [[patients]] are not [[reoriented ]] if reorientation causes [[agitation]]. <ref name=DR>{{cite journal|last=Flaherty|first=J.|coauthors=Little, M.|journal=Journal of the American Geriatrics Society|year=2011|volume=59|pages=295–300|doi=10.1111/j.1532-5415.2011.03678.x|title=Matching the Environment to Patients with Delirium: Lessons Learned from the Delirium Room, a Restraint-Free Environment for Older Hospitalized Adults with Delirium}}</ref>


Antipsychotics are the treatment of choice for distressing symptoms although ones with minimal [[anticholinergic]] activity, such as [[haloperidol]] or [[risperidone]] are preferable. Benzodiazepines are usually used in alcohol withdrawal.<br>
===[[Wandering]] and [[Rambling]] [[Speech]]===
* Treatment of underlying etiology important, as delirium can be reversible if diagnosed and treated correctly
* Wandering [[patients ]] needs close observation insecure and closed surroundings.
* Surrounding environment supports to help with orientation
* Distract agitated wandering [[patient]], relatives can prove helpful in curtailing [[agitation]].
* Psychosocial support
* If the [[patient]] is agitated, rule out common stressors such as [[pain]], [[thirst]], need for [[toilet]].
* Safety of environment
* It is not advisable to agree with [[rambling]] talk, instead one may follow the following strategies:
# Acknowledge the feelings expressed ‑ ignore the content
# Change the subject
# Tactfully disagree (if the topic is not [[sensitive]])


===[[Restrains]]===
*[[Physical]] restraints are often used as a last resort with [[patients]] in a severe [[delirium]].
* Restraint use should be avoided as it can increase [[agitation]] and risk of [[injury]].<ref name=Young>{{cite journal|last=Young|first=J.|coauthors=Inouye, S.|title=Delirium in older people|journal=British Medical Journal|year=2007|volume=334|pages=842–846|doi=10.1136/bmj.39169.706574.AD|pmid=17446616|issue=7598|pmc=1853193}}</ref>
* In order to avoid the use of restraints some [[patients]] may require constant supervision.
* Local laws on restrains must be well known to care providers.
*If non-pharmacological techniques fail, or if de-escalation techniques are inappropriate, only then pharmacological treatment is indicated.


==Medical Therapy==
==Medical Therapy==
Treatment of delirium involves two main strategies: first, treatment of the underlying presumed acute cause or causes; secondly, optimising conditions for the brain. This involves ensuring that the patient with delirium has adequate oxygenation, hydration, nutrition, and normal levels of metabolites, that drug effects are minimised, constipation treated, pain treated, and so on. Detection and management of mental stress is also very important. Therefore, the traditional concept that the treatment of delirium is 'treat the cause' is not adequate; patients with delirium actually require a highly detailed and expert analysis of all the factors which might be disrupting brain function.
*The maistay of [[medical]] therapy include:<ref name="pmid29535468">{{cite journal |vauthors=Grover S, Avasthi A |title=Clinical Practice Guidelines for Management of Delirium in Elderly |journal=Indian J Psychiatry |volume=60 |issue=Suppl 3 |pages=S329–S340 |date=February 2018 |pmid=29535468 |pmc=5840908 |doi=10.4103/0019-5545.224473 |url=}}</ref>
* [[Antipsychotics]] :[[haloperidol]], [[deroperidol]],[[chlorpromazine]], [[loxapine]], [[risperidone]], [[quetiapine]], [[olanzapine]], [[aripiprazole]], [[zuclopenthixol]], [[ziprasidone]], [[perospirone]]
* [[Benzodiazepines]]: [[lorazepam]])
* [[Cholinesterase inhibitors]]: [[donepezil]], [[rivastigmine]], [[physostigmine]]
* [[Highly selective a2 agonist]]: [[dexmedetomidine]]
* [[Melatonin]] based medication: [[remelteon]]


* In [[agitated]] [[patients]], [[midazolam]] combined with [[droperidol]] may be better than [[droperidol]] or o[[lanzapine]] alone.<ref name="pmid27745766">{{cite journal| author=Taylor DM, Yap CY, Knott JC, Taylor SE, Phillips GA, Karro J et al.| title=Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial. | journal=Ann Emerg Med | year= 2016 | volume=  | issue=  | pages=  | pmid=27745766 | doi=10.1016/j.annemergmed.2016.07.033 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27745766  }} </ref>


===Non-pharmacological treatments===
=====[[Antipsychotics]]=====
Non pharmacological methords are the first measure in delirium, unless there is severe agitation that places the person at risk of harming oneself or others.'''
*[[Haloperidol]] is a common treatment for [[delirium]].<ref name="pmid31890361">{{cite journal |vauthors=Zareifopoulos N, Panayiotakopoulos G |title=Treatment Options for Acute Agitation in Psychiatric Patients: Theoretical and Empirical Evidence |journal=Cureus |volume=11 |issue=11 |pages=e6152 |date=November 2019 |pmid=31890361 |pmc=6913952 |doi=10.7759/cureus.6152 |url=}}</ref>
* Avoiding unnecessary movement,
* Typical [[antipsychotic]] drug is a preferred drug in [[delirium]], because of its lower [[anticholinergic]] properties.
* involving family members,
* Use of [[haloperidol]] or [[ziprasidone]]  in [[ICU]] admitted [[patients]] with  acute [[respiratory failure]] or [[shock]] and [[hypoactive]] or [[hyperactive delirium]], was not effective in reduction of [[delirium]]. <ref name="pmid30346242">{{cite journal |vauthors=Girard TD, Exline MC, Carson SS, Hough CL, Rock P, Gong MN, Douglas IS, Malhotra A, Owens RL, Feinstein DJ, Khan B, Pisani MA, Hyzy RC, Schmidt GA, Schweickert WD, Hite RD, Bowton DL, Masica AL, Thompson JL, Chandrasekhar R, Pun BT, Strength C, Boehm LM, Jackson JC, Pandharipande PP, Brummel NE, Hughes CG, Patel MB, Stollings JL, Bernard GR, Dittus RS, Ely EW |title=Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness |journal=N Engl J Med |volume=379 |issue=26 |pages=2506–2516 |date=December 2018 |pmid=30346242 |pmc=6364999 |doi=10.1056/NEJMoa1808217 |url=}}</ref>
* having recognizable faces at the bedside,
*Low dose of [[haloperidol]] and [[olanzapine]]  have the same efficacy in treatment of [[delirium]].<ref name="pmid29497187">{{cite journal |vauthors=Jain R, Arun P, Sidana A, Sachdev A |title=Comparison of efficacy of haloperidol and olanzapine in the treatment of delirium |journal=Indian J Psychiatry |volume=59 |issue=4 |pages=451–456 |date=2017 |pmid=29497187 |pmc=5806324 |doi=10.4103/psychiatry.IndianJPsychiatry_59_17 |url=}}</ref>  
* having means of orientation available (such as a clock and a calendar) may be sufficient in stabilizing the situation.<ref name=NICE/><ref name=Inouye2006/>  
*Typically [[haloperidol]] dose differs with the  severity of symptoms and [[co-morbidity]] of the [[patients]].
* If this is insufficient, verbal and non-verbal de-escalation techniques may be required to offer reassurances and calm the person experiencing delirium.<ref name=NICE/>  


====The T-A-DA method (tolerate, anticipate, don't agitate====
{| border="2"
T-A-DA is an effective management technique for people with delirium.All unnecessary attachments are removed (IVs, catheters, NG tubes) which allows for greater mobility.<ref name=DR/> Patient behavior is tolerated even if it is not considered normal as long as it does not put the patient or other people in danger.<ref name=DR/> This technique requires that patients have close supervision to ensure that they remain safe.<ref name=DR/> Patient behavior is anticipated so care givers can plan required care. Patients are treated to reduce agitation.<ref name=DR/> Reducing agitation may mean that patients are not reoriented if reorientation causes agitation.<ref name=DR/>
|+ '''Dose of [[Haloperidol]]'''
! Geriatric [[population]], and seriously ill [[patients]]
| 0.25 - 0.50mg four hourly||
|-
! Healthier [[patients]]
| 2mg - 3mg  per day ||
|-
! Very [[agitated]] [[patients]]
|5mg - 10mg per hour iv
|}


<ref name=DR>{{cite journal|last=Flaherty|first=J.|coauthors=Little, M.|journal=Journal of the American Geriatrics Society|year=2011|volume=59|pages=295–300|doi=10.1111/j.1532-5415.2011.03678.x|title=Matching the Environment to Patients with Delirium: Lessons Learned from the Delirium Room, a Restraint-Free Environment for Older Hospitalized Adults with Delirium}}</ref>   
* [[Haloperidol]] can be administered orally, intramuscularly, or intravenously.
* IV route can reduce extrapyramidal side effects.
* Continuous IV infusions can be given instead of multiple IV bolus doses ([[haloperidol]] bolus, 10 mg i.v., followed by continuous intravenous infusion of 5–10 mg/hour).
*[[Droperidol]] has quick sedative effect in agitated [[patients]] with less [[respiratory]] or [[cardiac]] side effects. <ref name="HatzakorzianShan2006">{{cite journal|last1=Hatzakorzian|first1=R.|last2=Shan|first2=W. Li Pi|last3=Côté|first3=A. V.|last4=Schricker|first4=T.|last5=Backman|first5=S. B.|title=The management of severe emergence agitation using droperidol|journal=Anaesthesia|volume=61|issue=11|year=2006|pages=1112–1115|issn=0003-2409|doi=10.1111/j.1365-2044.2006.04791.x}}</ref>
* [[Antipsychotics]] are usually given for a short period of [[time]] approximately 1 week.<ref>{{Cite web  | last =  |first =  | title = http://www.nice.org.uk/nicemedia/live/13060/49909/49909.pdf | url = http://www.nice.org.uk/nicemedia/live/13060/49909/49909.pdf | publisher =  | date =  | accessdate = }}</ref>
*Long-acting [[olanzapine]] injection, sometimes may cause [[delirium]], this is known as a post-injection [[delirium]] [[sedation]] syndrome. <ref name="pmid20537130">{{cite journal |vauthors=McDonnell DP, Detke HC, Bergstrom RF, Kothare P, Johnson J, Stickelmeyer M, Sanchez-Felix MV, Sorsaburu S, Mitchell MI |title=Post-injection delirium/sedation syndrome in patients with schizophrenia treated with olanzapine long-acting injection, II: investigations of mechanism |journal=BMC Psychiatry |volume=10 |issue= |pages=45 |date=June 2010 |pmid=20537130 |pmc=2895590 |doi=10.1186/1471-244X-10-45 |url=}}</ref>
:* The presentation is similar to [[antipsychotic]] overdose.
:* Symptoms may range from [[confusion]], [[sedation]], [[dizziness]], to [[extrapyramidal]] effects.
* [[ Patients]] who require multiple bolus doses of [[antipsychotic]] [[medications]], [[continuous]] intravenous infusions of [[antipsychotic]] [[medication]] may be useful ( [[haloperidol]] bolus, 10 mg i.v., followed by continuous intravenous infusion of 510 mg/hour; lower doses may be required for elderly patients).
* For [[patients]] who require a more rapid onset of action, [[droperidol]], either alone or followed by [[haloperidol]], can be considered.
* [[Patient]] needs to be observed for 3 to 4 hours after administrating the [[injection]].
:*  [[Risperidol]] was found to be equivalent to [[haloperidol]] in terms of response rates and [[efficacy]].
* [[Resperidone]] was effective in medically hospitalized [[delirium]] [[patients]].<ref name="pmid15096074">{{cite journal |vauthors=Parellada E, Baeza I, de Pablo J, Martínez G |title=Risperidone in the treatment of patients with delirium |journal=J Clin Psychiatry |volume=65 |issue=3 |pages=348–53 |date=March 2004 |pmid=15096074 |doi=10.4088/jcp.v65n0310 |url=}}</ref>
*Low dose of [[haloperidol]] or [[chlorpromazine]] in hospitalized [[delirious]] [[patients]] were associated with less extrapyramidal side effects .<ref>{{cite journal|title=A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients|journal=American Journal of Psychiatry|volume=153|issue=2|year=1996|pages=231–237|issn=0002-953X|doi=10.1176/ajp.153.2.231}}</ref>
*'''[[HIV]]-associated [[delirium]]''' has been controlled by low dose of [[haloperidol]] and [[chloropromazine]].<ref name="WatkinsTreisman2015">{{cite journal|last1=Watkins|first1=Crystal|last2=Treisman|first2=Glenn|title=Cognitive impairment in patients with AIDS &ndash; prevalence and severity|journal=HIV/AIDS - Research and Palliative Care|year=2015|pages=35|issn=1179-1373|doi=10.2147/HIV.S39665}}</ref>
* In [[delirium ]] with [[psychosis]] associated [[HIV]], atypical antipsychotics such as [[clozapine]], [[risperidone]], and [[ziprasidone]] were effective.<ref name="pmid19358782">{{cite journal |vauthors=Brogan K, Lux J |title=Management of common psychiatric conditions in the HIV-positive population |journal=Curr HIV/AIDS Rep |volume=6 |issue=2 |pages=108–15 |date=May 2009 |pmid=19358782 |doi=10.1007/s11904-009-0016-x |url=}}</ref>


===[[Sedatives]]===
Indication for prescribing sedatives in [[delirium]]:<ref name="CleggYoung2010">{{cite journal|last1=Clegg|first1=A.|last2=Young|first2=J. B.|title=Which medications to avoid in people at risk of delirium: a systematic review|journal=Age and Ageing|volume=40|issue=1|year=2010|pages=23–29|issn=0002-0729|doi=10.1093/ageing/afq140}}</ref><ref name="PahwaQureshi2019">{{cite journal|last1=Pahwa|first1=Amit K|last2=Qureshi|first2=Imran|last3=Cumbler|first3=Ethan|title=Things We Do For No Reason: Use of Antipsychotic Medications in Patients with Delirium|journal=Journal of Hospital Medicine|volume=14|issue=9|year=2019|pages=565–567|issn=15535606|doi=10.12788/jhm.3166}}</ref>


===Restrains===
Physical restraints are often used as a last resort with patients in a severe delirium. Restraint use should be avoided as it can increase agitation and risk of injury.<ref name=Young>{{cite journal|last=Young|first=J.|coauthors=Inouye, S.|title=Delirium in older people|journal=British Medical Journal|year=2007|volume=334|pages=842–846|doi=10.1136/bmj.39169.706574.AD|pmid=17446616|issue=7598|pmc=1853193}}</ref>  In order to avoid the use of restraints some patients may require constant supervision.


If non pharmacological techniques fail, or if de-escalation techniques are inappropriate, only then pharmacological treatment is indicated.<ref name=NICE/><ref name=Inouye2006/>
# To conduct required diagnostic procedures or to deliver treatment
 
# If the [[patient]] is a danger to others or themselves
# Highly [[agitated]] or [[hallucinating]] [[patient]]
*Elderly [[patients ]] and [[delirium]] with [[hypoactive]] features do not require [[sedation]].
* All [[sedatives]] can cause [[delirium]], especially if drugs like [[thioridazine]], [[chlorpromazine]] which have [[anticholinergic]] effects.
* [[Sedatives]] must be used with caution with minimum possible dosage and should be discontinued if they are no longer required.
* [[Benzodiazepines]] can be beneficial in select cases of [[delirium]], such as:
* [[Alcholol]]  withdrawal
* [[Benzodiazepine withdrawal]]
* Contraindications of [[antipsychotics]]:
:# [[Parkinson's disease]]
:# [[Neuroleptic malignant syndrome]]
:# [[Dementia with Lewy bodies]]
*[[Benzodiazepines]] can cause [[delirium]] or may worsen the [[condition]].<ref name="pmid15254302">{{cite journal |vauthors=Alagiakrishnan K, Wiens CA |title=An approach to drug induced delirium in the elderly |journal=Postgrad Med J |volume=80 |issue=945 |pages=388–93 |date=July 2004 |pmid=15254302 |pmc=1743055 |doi=10.1136/pgmj.2003.017236 |url=}}</ref>
* Contraindications of benzodiazepines may include  [[hepatic]] [[encephalopathy]], [[respiratory]] depression or compromised lung functions.
* [[Benzodiazepines]] must be used with caution if [[liver]] functions are compromised.<ref>{{cite journal |author=Lonergan E, Luxenberg J, Areosa Sastre A, Wyller TB |title=Benzodiazepines for delirium |journal=Cochrane Database Syst Rev |volume= |issue=1 |pages=CD006379 |year=2009|pmid=19160280|doi=10.1002/14651858.CD006379.pub2 | url=http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/rel0002/CD006379/frame.html |editor1-last=Lonergan|editor1-first=Edmund}}</ref>
====[[Cholinergics]]====
*[[Physostygmine]] is used in  treatment of [[anticholinergic]] [[delirium ]].<ref name="ArensShah2017">{{cite journal|last1=Arens|first1=Ann M.|last2=Shah|first2=Krishna|last3=Al-Abri|first3=Suad|last4=Olson|first4=Kent R.|last5=Kearney|first5=Tom|title=Safety and effectiveness of physostigmine: a 10-year retrospective review|journal=Clinical Toxicology|volume=56|issue=2|year=2017|pages=101–107|issn=1556-3650|doi=10.1080/15563650.2017.1342828}}</ref>.<ref name="BoleyOlives2018">{{cite journal|last1=Boley|first1=Sean P.|last2=Olives|first2=Travis D.|last3=Bangh|first3=Stacey A.|last4=Fahrner|first4=Samuel|last5=Cole|first5=Jon B.|title=Physostigmine is superior to non-antidote therapy in the management of antimuscarinic delirium: a prospective study from a regional poison center|journal=Clinical Toxicology|volume=57|issue=1|year=2018|pages=50–55|issn=1556-3650|doi=10.1080/15563650.2018.1485154}}</ref>


====[[Morphine]] and [[Paralysis]]====
* Extremely agitated [[patients]], [[unresponsive]] to other treatment, may need [[sedation]] and [[ventilatory]] support.
* It increases [[oxygenation]] and [[skeletal]] muscle exertion.
*  [[Morphine]] is useful when [[pain]] is an important [[aggravating]] factor.
* [[Opiates]], especially [[meperidine]] can exacerbate [[delirium ]] because of their [[anticholinergic]] properties.
* [[Palliative]] treatment with [[opiates]] may be needed for [[patients]] with [[delirium]] for whom [[pain]] is an aggravating factor.


== Pharmacotherapy ==
====[[Antidepressants]]====
*The antidepressant [[trazodone]] with low dose is effective for treatment of [[delirium]].<ref name="MaedaInoue2021">{{cite journal|last1=Maeda|first1=Isseki|last2=Inoue|first2=Shinichiro|last3=Uemura|first3=Keiichi|last4=Tanimukai|first4=Hitoshi|last5=Hatano|first5=Yutaka|last6=Yokomichi|first6=Naosuke|last7=Amano|first7=Koji|last8=Tagami|first8=Keita|last9=Yoshiuchi|first9=Kazuhiro|last10=Ogawa|first10=Asao|last11=Iwase|first11=Satoru|last12=Achatz|first12=Eric|last13=Abo|first13=Hirofumi|last14=Akechi|first14=Tatsuo|last15=Akizuki|first15=Nobuya|last16=Fujisawa|first16=Daisuke|last17=Hagiwara|first17=Shingo|last18=Hirohashi|first18=Takeshi|last19=Hisanaga|first19=Takayuki|last20=Imai|first20=Kengo|last21=Inada|first21=Shuji|last22=Inoue|first22=Satoshi|last23=Iwata|first23=Aio|last24=Kaneishi|first24=Keisuke|last25=Kumano|first25=Akifumi|last26=Matsuda|first26=Yoshinobu|last27=Matsui|first27=Takashi|last28=Matsumoto|first28=Yoshihisa|last29=Matsuo|first29=Naoki|last30=Miyajima|first30=Kaya|last31=Mori|first31=Ichiro|last32=Morita|first32=Sachiyo|last33=Nakahara|first33=Rika|last34=Nakajima|first34=Nobuhisa|last35=Nobata|first35=Hiroyuki|last36=Odagiri|first36=Takuya|last37=Okuyama|first37=Toru|last38=Sakashita|first38=Akihiro|last39=Shimizu|first39=Ken|last40=contrib|first40=contrib|last41=Watanabe|first41=Yuki Sumazaki|last42=Takeuchi|first42=Emi|last43=Takeuchi|first43=Mari|last44=Tatara|first44=Ryohei|last45=Tokoro|first45=Akihiro|last46=Uchida|first46=Megumi|last47=Watanabe|first47=Hiroaki|last48=Yabuki|first48=Ritsuko|last49=Yamauchi|first49=Toshihiro|title=Low-Dose Trazodone for Delirium in Patients with Cancer Who Received Specialist Palliative Care: A Multicenter Prospective Study|journal=Journal of Palliative Medicine|year=2021|issn=1096-6218|doi=10.1089/jpm.2020.0610}}</ref>


=== Acute Pharmacotherapies ===  
===Individual and Family Psychological and [[Social]] Characteristics===
* [[Antipsychotics]]
*[[Psychodynamic]] issues, personality variables, and [[sociocultural]] environment are helpful in the management of specific [[anxieties]] and reaction patterns.
* [[Benzodiazepine]]s


===Discharge===
# The [[patient]] should be discharged after consulting all relevant disciplines in the hospital and outpatient care providers.
# Housing and living issues like [[washing]], [[dressing]], [[medication]] must be sorted out before the [[ patient]] is relieved from the [[hospital]].
# Cognitive and functional status (e.g. using standardized tools such as AMT and Barthel Index) must be accessed before discharge
# Discharge summaries must be complete and descriptive.
===Follow up===
*[[Delirium]] is an indication of serious illness, therefore [[delirium]] cases must be referred to a [[Geriatrician]], [[Psychiatrist]], [[Social Worker]], etc. for further workup and management.


===Antipsychotics====
==Unique Challenges in the Treatment of [[Delirium]]==
Haloperidol a typical antipsychotic drug is a preferred drug in delirium, because of its lower anticholinergic properties.
===Side effects of pharmacotherapy===
Typically doses of haloperidol differ for different subsets of patients.<ref name=NICE/><ref name=Inouye2006/> Evidence is weaker for the [[atypical antipsychotic]]s, such as [[risperidone]], [[olanzapine]] and [[quetiapine]].<refname=Inouye2006/><ref>{{cite book |editor1-first=Peter |editor1-last=Tyrer |editor2-first=Kenneth R. |editor2-last=Silk |title=Cambridge Textbook of Effective Treatments in Psychiatry |url=http://books.google.com/?id=HLPXELjTgdEC |edition=1st |date=24 January 2008 |publisher=Cambridge University Press |isbn=978-0-521-84228-0 |pages=175–184 |chapter=Delirium |chapterurl=http://books.google.co.uk/books?id=HLPXELjTgdEC&pg=PA175 }}</ref> British professional guidelines by the [[National Institute for Health and Clinical Excellence]] advise haloperidol or [[olanzapine]].<ref name=NICE/>
'''[[Antipsychotics]]''':
* [[ECG]] monitoring is required to calibrate [[QTc]] interval.
* [[Cardiology]] consult should be done if [[QTc]] interval is more than 450msec or it is greater than 25% baseline.  
*Low dose of [[haloperidol]] was not associated with [[QT]] prolongation in old [[patient]] admitted with [[delirium]].<ref name="pmid30108611">{{cite journal |vauthors=Schrijver EJ, Verstraaten M, van de Ven PM, Bet PM, van Strien AM, de Cock C, Nanayakkara PW |title=Low dose oral haloperidol does not prolong QTc interval in older acutely hospitalised adults: a subanalysis of a randomised double-blind placebo-controlled study |journal=J Geriatr Cardiol |volume=15 |issue=6 |pages=401–407 |date=June 2018 |pmid=30108611 |pmc=6087514 |doi=10.11909/j.issn.1671-5411.2018.06.003 |url=}}</ref>
* [[Haloperidol]] has can cause [[sedation]] and [[hypotension]].
* Side effects of [[antipsychotic]] [[medication]] include [[confusion]], [[cognitive]] and functional decline, [[sedation]], [[hypotension]], [[orthostasis]], [[dizziness]], [[falls]], [[urinary incontinence]], [[voiding]] problems, and increased risk of [[urinary infections]].<ref name="pmid25285270">{{cite journal |vauthors=Inouye SK, Marcantonio ER, Metzger ED |title=Doing Damage in Delirium: The Hazards of Antipsychotic Treatment in Elderly Persons |journal=Lancet Psychiatry |volume=1 |issue=4 |pages=312–315 |date=September 2014 |pmid=25285270 |pmc=4180215 |doi=10.1016/S2215-0366(14)70263-9 |url=}}</ref>
''''[[Bezodiazepines]]'''': Can cause behavioral dis-inhibition, [[amnesia]], [[ataxia]], [[respiratory]] depression, [[physical]] dependence, rebound [[insomnia]], withdrawal reactions, and [[delirium]].
* [[Adolescents]] and [[pediatric]] may suffer from disinhibition reactions, [[emotional lability]], increased [[anxiety]], [[hallucinations]], aggression, [[insomnia]], [[euphoria]], and in-coordination.
'''[[Anticholinergics]]''' Causes [[dizziness]], [[blurred vision]], [[urinary retention]], [[constipation]], [[confusion]], and [[delirium]].<ref name="CollamatiMartone2015">{{cite journal|last1=Collamati|first1=Agnese|last2=Martone|first2=Anna Maria|last3=Poscia|first3=Andrea|last4=Brandi|first4=Vincenzo|last5=Celi|first5=Michela|last6=Marzetti|first6=Emanuele|last7=Cherubini|first7=Antonio|last8=Landi|first8=Francesco|title=Anticholinergic drugs and negative outcomes in the older population: from biological plausibility to clinical evidence|journal=Aging Clinical and Experimental Research|volume=28|issue=1|year=2015|pages=25–35|issn=1720-8319|doi=10.1007/s40520-015-0359-7}}</ref>
* [[Physostigmine]] can cause [[seizures]].<ref name="pmid30747326">{{cite journal |vauthors=Arens AM, Kearney T |title=Adverse Effects of Physostigmine |journal=J Med Toxicol |volume=15 |issue=3 |pages=184–191 |date=July 2019 |pmid=30747326 |pmc=6597673 |doi=10.1007/s13181-019-00697-z |url=}}</ref>


===Education and Reassurement===
* It is important for [[psychiatrists]] to help [[patients]] understand [[symptoms]] of [[delirium]], by explaining transient nature of [[delirium]] can help [[patients]] and their families in coping.
* As [[delirium]] is accompanied by behavioral changes, sometimes [[physicians]] and nursing staff may overlook the underlying [[medical]] [[condition]] responsible for [[delirium]], therefore it is an important task for a [[psychiatrist]] to educate [[medical]] care provider about [[delirium]].


0.25 - 0.50mg four hourly, for the geriatric population, and seriously ill patients.
===Post [[Delirium]] [[Psychiatric]] Management===
2mg  - 3mg  per day in healthier patients.  However for very agitated patients.
* Post recovery [[patients]] may remember their experiences during [[delirium]].  
5mg  - 10mg per hour iv dose has been used in the inpatient settings.  
* This can cause significant distress in the [[patients]].   
 
*[[Symptoms]] may range from having [[vivid]], [[frightening]] recollections.
Lowest possible antipsychotic doses should be given. For more sever agitation antipsychotics are supplemented  with benzodiazepines and  ventilator support.
* Reassurance and explanation of [[condition]] can ease some [[stress]].
 
* Standard [[psychiatric]] interventions utilized following [[traumatic]] experiences should be used.
Combination of haloperidol and chlorpromazine has also been tried in few studies with positive outcomes. .<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Delirium and antipsychotics: a systemat... [Psychiatry (Edgmont). 2008] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/19724721 | publisher =  | date =  | accessdate = }}</ref>
* [[Psychotherapy]] can be helpful relieving [[anxiety]], [[guilt]], [[anger]], [[depression]], or other [[emotional]] states.
 
===Competency===
===Benzodiazepines===
*Because of transient impairment in [[cognition]], [[orientation]] and other higher functions, the [[patient]] may not be able to provide consent or there can be impairment of competency.  
Benzodiazepines themselves can cause delirium or worsen it,<ref name=Inouye2006/> and lack a reliable evidence base.<ref>{{cite journal |author=Lonergan E, Luxenberg J, Areosa Sastre A, Wyller TB |title=Benzodiazepines for delirium |journal=Cochrane Database Syst Rev |volume= |issue=1 |pages=CD006379 |year=2009|pmid=19160280 |doi=10.1002/14651858.CD006379.pub2 | url=http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/rel0002/CD006379/frame.html |editor1-last=Lonergan |editor1-first=Edmund}}</ref> However, if delirium is due to [[alcohol withdrawal]] or [[benzodiazepine withdrawal]] or if antipsychotics are contraindicated (e.g. in [[Parkinson's disease]] or [[neuroleptic malignant syndrome]]), then benzodiazepines are recommended.<ref name=Inouye2006/> Similarly, people with [[dementia with Lewy bodies]] may have significant side-effects to antipsychotics, and should either be treated with a small dose or not at all.<ref name=NICE/>
* [[Delirium]] itself does not make the [[patient]] incompetent by law. 
 
* [[Emergency]] cases can be treated without obtaining consent however non [[emergency ]] cases pose an [[ethical]] dilemmas.
===Antidepressants===
===[[Elderly]]===
The antidepressant [[trazodone]] is occasionally used in the treatment of delirium, but it carries a risk of oversedation, and its use has not been well studied.<ref name=Inouye2006/>
*[[Antipsychotic]] drugs can cause serious side effects in the [[geriatric]] population.
* Even though [[antipsychotic]] [[medications]] is prescribed for a shorter duration of [[time]] in [[delirium]], it caution must be practiced.  
* Side effects of [[antipsychotic]] drug include:
:*[[Extra-pyramidal]] side effects
:*[[Falling]]
:*[[Hip]] fracture  <ref>{{Cite web  | last =  | first =  | title = Antipsychotic therapy and short-term serious... [Arch Intern Med. 2008] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/18504337 | publisher =  | date =  | accessdate = }}</ref>
*Low dose of [[haloperidol]] was not associated with [[extrapyramidal]] side effect in [[delirium]] [[patients]].<ref>{{cite journal|doi=10.4088/JCP.14m09098.}}</ref><ref name="LonerganBritton2007">{{cite journal|last1=Lonergan|first1=Edmund|last2=Britton|first2=Annette M|last3=Luxenberg|first3=Jay|last4=Lonergan|first4=Edmund|title=Antipsychotics for delirium|year=2007|doi=10.1002/14651858.CD005594.pub2}}</ref>
==== Treatment of Reversible Causes of [[Delirium]]====
Identify reversible causes of [[delirium]] and treat them promptly:
''' Suspected [[Hypoglycemia]] '''
:* IV [[Thiamine]]
:* IV [[glucose]]
'''[[Hypoxia]] or [[anoxia]]''' (secondary to [[pulmonary]] disease, [[cardiac]] problems, [[hypotension]], severe [[anemia]], [[CO]] poisoning)
:* Prompt treatment with [[oxygen]]
'''[[Hyperthermia]]'''
:* Rapid [[cooling]]
'''Severe [[hypertension]]'''
:* Urgent administration of [[antihypertensive]] medications
'''[[Alcohol]] or sedative withdrawal'''
:* [[Thiamine]], [[folate]] and other [[B vitamins]]
:* Intravenous [[Glucose]]
:* [[Magnesium]]
:* [[Phosphate]].
'''[[Wernicke’s encephalopathy]]''':
:* [[Thiamine]] hydrochloride i.v. and followed by daily oral or IM doses
'''[[Anticholinergic]] [[delirium]]''':<ref name="pmid26589572">{{cite journal |vauthors=Dawson AH, Buckley NA |title=Pharmacological management of anticholinergic delirium - theory, evidence and practice |journal=Br J Clin Pharmacol |volume=81 |issue=3 |pages=516–24 |date=March 2016 |pmid=26589572 |pmc=4767198 |doi=10.1111/bcp.12839 |url=}}</ref>
:* Withdrawal of offending agent
:*  [[physostigmine]]
* [[Multivitamin]] replacement is required if [[B vitamin]] deficiencies are suspected.([[alcoholic]] or [[malnourished]]).<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Practice guideline for the treatment of pati... [Am J Psychiatry. 1999] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/10327941 | publisher =  | date =  | accessdate = }}</ref>


==References==
==References==

Latest revision as of 11:08, 22 April 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Pratik Bahekar, MBBS [3] ; Vishal Khurana, M.B.B.S., M.D. [4]

Overview

Treatment of delirium involves two main strategies: first, treatment of the underlying presumed acute cause or causes, secondly, optimizing conditions of the brain. This involves ensuring that the patient with delirium has adequate oxygenation, hydration, nutrition, and normal levels of metabolites, so that drug effects are minimized, constipation treated, pain treated, and so on. Detection and management of mental stress are also very important. Therefore, the traditional concept that the treatment of delirium is treating the cause is not adequate. Common medications is used for delirium treatment include antipsychotic drugs, benzodiazepines, cholinestrase inhibitors, selective -a2 receptor agonist, melatonin based medications, ketamine.

Non-Pharmacological Treatments

  • Delirium is not a disease, but a syndrome (collection of symptoms) indicating dysfunction of the brain.
  • Treatment of delirium is achieved by treating the underlying dysfunction cause.
  • Non-pharmacological methods are the first measure in delirium unless there is severe agitation that places the person at risk of harming oneself or others.
  • Avoiding unnecessary movement
  • Avoidance of inter-and intra‑ward transfers
  • Continuity of care from caring staff
  • Avoidance of physical restraints
  • Involving family members
  • Having recognizable faces at the bedside
  • Sensory aids should be available and working where necessary
  • Maintenance or restoration of normal sleep patterns
  • Approach and handle gently
  • Avoid sudden and irritating noise (Pump alarms)
  • Careful management of bowel and bladder elimination
  • Having a means of orientation available (such as a clock and a calendar) may be sufficient in stabilizing the situation
  • Reassurance and explanation to the patient and carer of any procedures or treatment, using short simple sentences
  • If this is insufficient, verbal and non-verbal de-escalation techniques may be required to offer reassurances and calm the person experiencing delirium.[1]

{{#ev:youtube|hwz9M2jZi_o}} {{#ev:youtube|mKcbeXVdygg}}

The T-A-DA Method (Tolerate, Anticipate, Don't Agitate)

Wandering and Rambling Speech

  • Wandering patients needs close observation insecure and closed surroundings.
  • Distract agitated wandering patient, relatives can prove helpful in curtailing agitation.
  • If the patient is agitated, rule out common stressors such as pain, thirst, need for toilet.
  • It is not advisable to agree with rambling talk, instead one may follow the following strategies:
  1. Acknowledge the feelings expressed ‑ ignore the content
  2. Change the subject
  3. Tactfully disagree (if the topic is not sensitive)

Restrains

  • Physical restraints are often used as a last resort with patients in a severe delirium.
  • Restraint use should be avoided as it can increase agitation and risk of injury.[5]
  • In order to avoid the use of restraints some patients may require constant supervision.
  • Local laws on restrains must be well known to care providers.
  • If non-pharmacological techniques fail, or if de-escalation techniques are inappropriate, only then pharmacological treatment is indicated.

Medical Therapy

Antipsychotics
Dose of Haloperidol
Geriatric population, and seriously ill patients 0.25 - 0.50mg four hourly
Healthier patients 2mg - 3mg per day
Very agitated patients 5mg - 10mg per hour iv
  • Haloperidol can be administered orally, intramuscularly, or intravenously.
  • IV route can reduce extrapyramidal side effects.
  • Continuous IV infusions can be given instead of multiple IV bolus doses (haloperidol bolus, 10 mg i.v., followed by continuous intravenous infusion of 5–10 mg/hour).
  • Droperidol has quick sedative effect in agitated patients with less respiratory or cardiac side effects. [11]
  • Antipsychotics are usually given for a short period of time approximately 1 week.[12]
  • Long-acting olanzapine injection, sometimes may cause delirium, this is known as a post-injection delirium sedation syndrome. [13]

Sedatives

Indication for prescribing sedatives in delirium:[18][19]


  1. To conduct required diagnostic procedures or to deliver treatment
  2. If the patient is a danger to others or themselves
  3. Highly agitated or hallucinating patient
  1. Parkinson's disease
  2. Neuroleptic malignant syndrome
  3. Dementia with Lewy bodies

Cholinergics

Morphine and Paralysis

Antidepressants

Individual and Family Psychological and Social Characteristics

Discharge

  1. The patient should be discharged after consulting all relevant disciplines in the hospital and outpatient care providers.
  2. Housing and living issues like washing, dressing, medication must be sorted out before the patient is relieved from the hospital.
  3. Cognitive and functional status (e.g. using standardized tools such as AMT and Barthel Index) must be accessed before discharge
  4. Discharge summaries must be complete and descriptive.

Follow up

Unique Challenges in the Treatment of Delirium

Side effects of pharmacotherapy

Antipsychotics:

'Bezodiazepines': Can cause behavioral dis-inhibition, amnesia, ataxia, respiratory depression, physical dependence, rebound insomnia, withdrawal reactions, and delirium.

Anticholinergics Causes dizziness, blurred vision, urinary retention, constipation, confusion, and delirium.[27]

Education and Reassurement

Post Delirium Psychiatric Management

Competency

  • Because of transient impairment in cognition, orientation and other higher functions, the patient may not be able to provide consent or there can be impairment of competency.
  • Delirium itself does not make the patient incompetent by law.
  • Emergency cases can be treated without obtaining consent however non emergency cases pose an ethical dilemmas.

Elderly

Treatment of Reversible Causes of Delirium

Identify reversible causes of delirium and treat them promptly: Suspected Hypoglycemia

Hypoxia or anoxia (secondary to pulmonary disease, cardiac problems, hypotension, severe anemia, CO poisoning)

Hyperthermia

Severe hypertension

Alcohol or sedative withdrawal

Wernicke’s encephalopathy:

  • Thiamine hydrochloride i.v. and followed by daily oral or IM doses

Anticholinergic delirium:[32]

References

  1. "Delirium".
  2. "Delirium".
  3. "Matching the Environment to Patients with Delirium: Lessons Learned from the Delirium Room, a Restraint‐Free Environment for Older Hospitalized Adults with Delirium - Flaherty -2011 - Journal of the American Geriatrics Society - Wiley Online Library".
  4. Flaherty, J. (2011). "Matching the Environment to Patients with Delirium: Lessons Learned from the Delirium Room, a Restraint-Free Environment for Older Hospitalized Adults with Delirium". Journal of the American Geriatrics Society. 59: 295–300. doi:10.1111/j.1532-5415.2011.03678.x. Unknown parameter |coauthors= ignored (help)
  5. Young, J. (2007). "Delirium in older people". British Medical Journal. 334 (7598): 842–846. doi:10.1136/bmj.39169.706574.AD. PMC 1853193. PMID 17446616. Unknown parameter |coauthors= ignored (help)
  6. Grover S, Avasthi A (February 2018). "Clinical Practice Guidelines for Management of Delirium in Elderly". Indian J Psychiatry. 60 (Suppl 3): S329–S340. doi:10.4103/0019-5545.224473. PMC 5840908. PMID 29535468.
  7. Taylor DM, Yap CY, Knott JC, Taylor SE, Phillips GA, Karro J; et al. (2016). "Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial". Ann Emerg Med. doi:10.1016/j.annemergmed.2016.07.033. PMID 27745766.
  8. Zareifopoulos N, Panayiotakopoulos G (November 2019). "Treatment Options for Acute Agitation in Psychiatric Patients: Theoretical and Empirical Evidence". Cureus. 11 (11): e6152. doi:10.7759/cureus.6152. PMC 6913952 Check |pmc= value (help). PMID 31890361.
  9. Girard TD, Exline MC, Carson SS, Hough CL, Rock P, Gong MN, Douglas IS, Malhotra A, Owens RL, Feinstein DJ, Khan B, Pisani MA, Hyzy RC, Schmidt GA, Schweickert WD, Hite RD, Bowton DL, Masica AL, Thompson JL, Chandrasekhar R, Pun BT, Strength C, Boehm LM, Jackson JC, Pandharipande PP, Brummel NE, Hughes CG, Patel MB, Stollings JL, Bernard GR, Dittus RS, Ely EW (December 2018). "Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness". N Engl J Med. 379 (26): 2506–2516. doi:10.1056/NEJMoa1808217. PMC 6364999. PMID 30346242.
  10. Jain R, Arun P, Sidana A, Sachdev A (2017). "Comparison of efficacy of haloperidol and olanzapine in the treatment of delirium". Indian J Psychiatry. 59 (4): 451–456. doi:10.4103/psychiatry.IndianJPsychiatry_59_17. PMC 5806324. PMID 29497187.
  11. Hatzakorzian, R.; Shan, W. Li Pi; Côté, A. V.; Schricker, T.; Backman, S. B. (2006). "The management of severe emergence agitation using droperidol". Anaesthesia. 61 (11): 1112–1115. doi:10.1111/j.1365-2044.2006.04791.x. ISSN 0003-2409.
  12. "http://www.nice.org.uk/nicemedia/live/13060/49909/49909.pdf" (PDF). External link in |title= (help)
  13. McDonnell DP, Detke HC, Bergstrom RF, Kothare P, Johnson J, Stickelmeyer M, Sanchez-Felix MV, Sorsaburu S, Mitchell MI (June 2010). "Post-injection delirium/sedation syndrome in patients with schizophrenia treated with olanzapine long-acting injection, II: investigations of mechanism". BMC Psychiatry. 10: 45. doi:10.1186/1471-244X-10-45. PMC 2895590. PMID 20537130.
  14. Parellada E, Baeza I, de Pablo J, Martínez G (March 2004). "Risperidone in the treatment of patients with delirium". J Clin Psychiatry. 65 (3): 348–53. doi:10.4088/jcp.v65n0310. PMID 15096074.
  15. "A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients". American Journal of Psychiatry. 153 (2): 231–237. 1996. doi:10.1176/ajp.153.2.231. ISSN 0002-953X.
  16. Watkins, Crystal; Treisman, Glenn (2015). "Cognitive impairment in patients with AIDS – prevalence and severity". HIV/AIDS - Research and Palliative Care: 35. doi:10.2147/HIV.S39665. ISSN 1179-1373.
  17. Brogan K, Lux J (May 2009). "Management of common psychiatric conditions in the HIV-positive population". Curr HIV/AIDS Rep. 6 (2): 108–15. doi:10.1007/s11904-009-0016-x. PMID 19358782.
  18. Clegg, A.; Young, J. B. (2010). "Which medications to avoid in people at risk of delirium: a systematic review". Age and Ageing. 40 (1): 23–29. doi:10.1093/ageing/afq140. ISSN 0002-0729.
  19. Pahwa, Amit K; Qureshi, Imran; Cumbler, Ethan (2019). "Things We Do For No Reason: Use of Antipsychotic Medications in Patients with Delirium". Journal of Hospital Medicine. 14 (9): 565–567. doi:10.12788/jhm.3166. ISSN 1553-5606.
  20. Alagiakrishnan K, Wiens CA (July 2004). "An approach to drug induced delirium in the elderly". Postgrad Med J. 80 (945): 388–93. doi:10.1136/pgmj.2003.017236. PMC 1743055. PMID 15254302.
  21. Lonergan E, Luxenberg J, Areosa Sastre A, Wyller TB (2009). Lonergan, Edmund, ed. "Benzodiazepines for delirium". Cochrane Database Syst Rev (1): CD006379. doi:10.1002/14651858.CD006379.pub2. PMID 19160280.
  22. Arens, Ann M.; Shah, Krishna; Al-Abri, Suad; Olson, Kent R.; Kearney, Tom (2017). "Safety and effectiveness of physostigmine: a 10-year retrospective review". Clinical Toxicology. 56 (2): 101–107. doi:10.1080/15563650.2017.1342828. ISSN 1556-3650.
  23. Boley, Sean P.; Olives, Travis D.; Bangh, Stacey A.; Fahrner, Samuel; Cole, Jon B. (2018). "Physostigmine is superior to non-antidote therapy in the management of antimuscarinic delirium: a prospective study from a regional poison center". Clinical Toxicology. 57 (1): 50–55. doi:10.1080/15563650.2018.1485154. ISSN 1556-3650.
  24. Maeda, Isseki; Inoue, Shinichiro; Uemura, Keiichi; Tanimukai, Hitoshi; Hatano, Yutaka; Yokomichi, Naosuke; Amano, Koji; Tagami, Keita; Yoshiuchi, Kazuhiro; Ogawa, Asao; Iwase, Satoru; Achatz, Eric; Abo, Hirofumi; Akechi, Tatsuo; Akizuki, Nobuya; Fujisawa, Daisuke; Hagiwara, Shingo; Hirohashi, Takeshi; Hisanaga, Takayuki; Imai, Kengo; Inada, Shuji; Inoue, Satoshi; Iwata, Aio; Kaneishi, Keisuke; Kumano, Akifumi; Matsuda, Yoshinobu; Matsui, Takashi; Matsumoto, Yoshihisa; Matsuo, Naoki; Miyajima, Kaya; Mori, Ichiro; Morita, Sachiyo; Nakahara, Rika; Nakajima, Nobuhisa; Nobata, Hiroyuki; Odagiri, Takuya; Okuyama, Toru; Sakashita, Akihiro; Shimizu, Ken; contrib, contrib; Watanabe, Yuki Sumazaki; Takeuchi, Emi; Takeuchi, Mari; Tatara, Ryohei; Tokoro, Akihiro; Uchida, Megumi; Watanabe, Hiroaki; Yabuki, Ritsuko; Yamauchi, Toshihiro (2021). "Low-Dose Trazodone for Delirium in Patients with Cancer Who Received Specialist Palliative Care: A Multicenter Prospective Study". Journal of Palliative Medicine. doi:10.1089/jpm.2020.0610. ISSN 1096-6218.
  25. Schrijver EJ, Verstraaten M, van de Ven PM, Bet PM, van Strien AM, de Cock C, Nanayakkara PW (June 2018). "Low dose oral haloperidol does not prolong QTc interval in older acutely hospitalised adults: a subanalysis of a randomised double-blind placebo-controlled study". J Geriatr Cardiol. 15 (6): 401–407. doi:10.11909/j.issn.1671-5411.2018.06.003. PMC 6087514. PMID 30108611.
  26. Inouye SK, Marcantonio ER, Metzger ED (September 2014). "Doing Damage in Delirium: The Hazards of Antipsychotic Treatment in Elderly Persons". Lancet Psychiatry. 1 (4): 312–315. doi:10.1016/S2215-0366(14)70263-9. PMC 4180215. PMID 25285270.
  27. Collamati, Agnese; Martone, Anna Maria; Poscia, Andrea; Brandi, Vincenzo; Celi, Michela; Marzetti, Emanuele; Cherubini, Antonio; Landi, Francesco (2015). "Anticholinergic drugs and negative outcomes in the older population: from biological plausibility to clinical evidence". Aging Clinical and Experimental Research. 28 (1): 25–35. doi:10.1007/s40520-015-0359-7. ISSN 1720-8319.
  28. Arens AM, Kearney T (July 2019). "Adverse Effects of Physostigmine". J Med Toxicol. 15 (3): 184–191. doi:10.1007/s13181-019-00697-z. PMC 6597673 Check |pmc= value (help). PMID 30747326.
  29. "Antipsychotic therapy and short-term serious... [Arch Intern Med. 2008] - PubMed - NCBI".
  30. . doi:10.4088/JCP.14m09098. Check |doi= value (help). Missing or empty |title= (help)
  31. Lonergan, Edmund; Britton, Annette M; Luxenberg, Jay; Lonergan, Edmund (2007). "Antipsychotics for delirium". doi:10.1002/14651858.CD005594.pub2.
  32. Dawson AH, Buckley NA (March 2016). "Pharmacological management of anticholinergic delirium - theory, evidence and practice". Br J Clin Pharmacol. 81 (3): 516–24. doi:10.1111/bcp.12839. PMC 4767198. PMID 26589572.
  33. "Practice guideline for the treatment of pati... [Am J Psychiatry. 1999] - PubMed - NCBI".

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