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]

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.

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.
• 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 doses of haloperidol differ for different subsets of patients.

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, and extrapyramidal effects. Patients needs to be observed for 3 to 4 hours after administrating the injection.

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.

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.