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]

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 causes (plural), as delirium is often multi-factorial. 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,
• 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 (e.g. 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.

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. 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.

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. 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.

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 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.

Pharmacotherapy

Acute Pharmacotherapies

• Antipsychotics
• Benzodiazepines

Antipsychotics

Haloperidol is considered as a gold standard treatment for delirium. Typical antipsychotic drug is a preferred drug in delirium, because of its lower anticholinergic properties. Amongst atypical antipsychotics olanzapine is used along alone or adjuvalent to haloperidol, others, such as risperidone, quetiapine, Ziprasidone, and aripiprazole have shown promising results in the clinical studies.

British professional guidelines of the National Institute for Health and Clinical Excellence advise haloperidol or olanzapine.

Typically haloperidol dose differs wrt severity of symptoms and comorbidity of the patients.

Always start with lowest dose and titrate it up. Antipsychotics are usually given for short period of time- approximately 1 week.

For more sever agitation antipsychotics are supplemented with benzodiazepines and ventilator support.

Long acting olanzapine injection, sometimes may cause delirium, this is known as a post-injection delirium sedation syndrome. It's presentation is similar to antipsychotic overdose. Symptomology may range from confusion, sedation, dizziness, to extrapyramidal effects. Patient needs to be observed for 3 to 4 hours after administrating the injection.

Risperidol at 0.75mg per day to 3.1mg per day has demonstrated moderate to marked improvement of in delirium on the Clinical Global Impressions Scale, Brief Psychiatric Rating Scale, and Trzepacz Delirium Rating Scale. Risperidol was found to be equivalent to haloperidol in terms of response rates and efficacy.

The combination of haloperidol and chlorpromazine has also been tried in a few studies with positive outcomes.

HIV-associated delirium has been effectively controlled by molindone- 40 to 140mg per day, however, more studies are required to validate this approach.

Benzodiazepines

Benzodiazepines themselves can cause delirium or worsen it, and lack a reliable evidence base. 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. 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.

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.

Wandering and rambling speech

Patients who wander require close observation within a safe and reasonably closed environment. It is often preferable to try distracting the agitated wandering patient rather than using restraints or sedation. Relatives could be encouraged to assist in this kind of management.

Attempts should be made to identify and remedy possible cause of agitation ‑ e.g. pain, thirst, need for toilet. Patients with delirium often exhibit confused and rambling speech, it is usually preferable not to agree with rambling talk, but to adopt one of the following strategies, depending on the circumstance (grade III) [40]:

· Tactfully disagree (if the topic is not sensitive)

· Change the subject

· Acknowledge the feelings expressed ‑ ignore the content

Sedation

All sedatives may cause delirium, especially those with anticholinergic side effects [41] (such as thioridazine, chlorpromazine etc.). The use of sedatives and major tranquillisers should therefore be kept to a minimum (grade III). Many elderly patients with delirium have hypoactive delirium (quiet delirium) and do not require sedation [42]. Early identification of delirium and prompt treatment of the underlying cause may reduce the severity and duration of delirium [24‑26].

Drug sedation may be necessary in the following circumstances (grade III)

· in order to carry out essential investigations or treatment

· to prevent patients endangering themselves or others

· to relieve distress in a highly agitated or hallucinating patient

It is preferable to use one drug only, starting at the lowest possible dose and increasing in increments if necessary after an interval of 30 minutes (grade III).

The preferred drugs are:

· Haloperidol - 0.5mg‑3mg orally as tablets or liquid up to 4 times daily or 2.5 ‑ 5 mg by

intramuscular injection (grade III) (NB the oral and IM doses of haloperidol are not equivalent)

· Droperidol - 5‑10mg orally or 5mg by intramuscular injection up to 4 times daily.

If sedatives are prescribed, the prescription should be reviewed regularly and discontinued as soon as possible.

For delirium due to alcohol withdrawal (delirium tremens) a benzodiazepine (eg diazepam or chlordiazepoxide) or chlormethiazole are preferred in a reducing course. Detailed guidelines for this condition are beyond the scope of these guidelines.

Referral to Old Age Psychiatry services

Many patients with delirium have an underlying dementia which may be best followed up and managed by an Old Age Psychiatrist. Patients who fail to improve despite adequate treatment and resolution of the suspected cause of the delirium may benefit from referral to an Old Age Psychiatrist for further assessment (grade III) [35].

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Discharge

As with all elderly patients discharge should be planned in conjunction with all disciplines involved in caring for the patient, both in hospital and in the community (including informal carers). Practical arrangements should be in place prior to discharge for activities such as washing, dressing, medication etc. in accordance with the joint statement of the British Geriatrics Society and the Association Directors of Social Services [43] (grade III).

· Communication with all parties involved in the patients care is vital.

· Prior to discharge it is useful to assess the patients cognitive and functional status ( eg using standardised tools such as AMT and Barthel Index).

· Discharge summaries should be completed promptly.

Follow up

Delirium is a common first presentation of an underlying dementing process. It may also be a marker of severe illness and comorbidity. It is therefore often appropriate to refer the patient to a Geriatrician, Psychiatrist of Old Age, CPN or Social Worker for the Elderly or Consultant in Geriatric Medicine for further assessment and follow up.