Delirium medical therapy

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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 '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. This involves ensuring that the patient with delirium has adequate oxygenation, hydration, nutrition, and normal levels of metabolites, that drug effects are minimized, constipation treated, pain treated, and so on. Detection and management of mental stress is also very important.

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]

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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

Pharmacotherapy

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

Sedatives

Indication for prescribing sedatives in delirium:[18]

  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

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:[23]

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.[24]

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

References

  1. "Delirium".
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  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. 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.
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  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. "http://www.nice.org.uk/nicemedia/live/13060/49909/49909.pdf" (PDF). External link in |title= (help)
  14. 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.
  15. 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.
  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. 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.
  20. 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.
  21. 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.
  22. 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.
  23. 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.
  24. 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.
  25. 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.
  26. "Antipsychotic therapy and short-term serious... [Arch Intern Med. 2008] - PubMed - NCBI".

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