Delirium medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vishal Khurana, M.B.B.S., M.D. [2]; Pratik Bahekar, MBBS [3]
Overview
Treatment of Delirium
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 causes (plural), as delirium is often multi-factorial.
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.
- Treatment of underlying etiology important, as delirium can be reversible if diagnosed and treated correctly
- Surrounding environment supports to help with orientation
- Psychosocial support
- Safety of environment
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.
Non-pharmacological treatments
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.
- Avoiding unnecessary movement,
- involving family members,
- having recognizable faces at the bedside,
- having means of orientation available (such as a clock and a calendar) may be sufficient in stabilizing the situation.[1][2]
- If this is insufficient, verbal and non-verbal de-escalation techniques may be required to offer reassurances and calm the person experiencing delirium.[1]
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.[3] 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.[3] This technique requires that patients have close supervision to ensure that they remain safe.[3] Patient behavior is anticipated so care givers can plan required care. Patients are treated to reduce agitation.[3] Reducing agitation may mean that patients are not reoriented if reorientation causes agitation.[3]
”[3]
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.[4] 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.[1][2]
Pharmacotherapy
Acute Pharmacotherapies
Antipsychotics
Haloperidol a typical antipsychotic drug is a preferred drug in delirium, because of its lower anticholinergic properties. Typically doses of haloperidol differ for different subsets of patients.[1][2] Evidence is weaker for the atypical antipsychotics, such as risperidone, olanzapine and quetiapine.<refname=Inouye2006/>[5] British professional guidelines by the National Institute for Health and Clinical Excellence advise haloperidol or olanzapine.[1]
0.25 - 0.50mg four hourly, for the geriatric population, and seriously ill patients.
2mg - 3mg per day in healthier patients. However, for very agitated patients.
5mg - 10mg per hour iv dose has been used in the inpatient settings.
Lowest possible antipsychotic doses should be given. For more sever agitation antipsychotics are supplemented with benzodiazepines and ventilator support.
The combination of haloperidol and chlorpromazine has also been tried in a few studies with positive outcomes.[6]
Benzodiazepines
Benzodiazepines themselves can cause delirium or worsen it,[2] and lack a reliable evidence base.[7] 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.[2] 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.[1]
Antidepressants
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.[2]
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 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) - ↑ 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) - ↑ Tyrer, Peter; Silk, Kenneth R., eds. (24 January 2008). "Delirium". Cambridge Textbook of Effective Treatments in Psychiatry (1st ed.). Cambridge University Press. pp. 175–184. ISBN 978-0-521-84228-0.
- ↑ "Delirium and antipsychotics: a systemat... [Psychiatry (Edgmont). 2008] - PubMed - NCBI".
- ↑ 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.