Consider Antipsychotics for Severe Delirium

Delirium prevention and early treatment reduce complications and mortality.
Abdelwahab Ward, BS Pharm, PharmD

As a critical care pharmacist, you'll see more focus on preventing and treating delirium. At least one-third of older hospitalized patients have a sudden onset of cognitive impairment, altered consciousness, hallucinations, etc. Patients are at highest risk after surgery or if they have dementia or a severe illness.

NPS-adv

Help prevent delirium, or treat it early, to reduce complications and mortality.

  • Reduce medication triggers.
    • Try to minimize the number of meds and use the lowest effective doses.
    • Also try to stop meds linked to delirium sedating antihistamines (diphenhydramine, etc), overactive bladder drugs, benzodiazepines, non-benzo hypnotics, opioids, dopamine agonists, and others.
  • Look for meds that can cause dehydration or constipation. Ensure patients get adequate fluids and a bowel regimen if needed.
  • Treat pain adequately and avoid meperidine.
  • Keep patients oriented. Encourage using clocks, calendars, family photos, etc, and eyeglasses or hearing aids if needed.
  • Watch for signs. Use a quick screening test when appropriate, such as asking patients to say the months of the year backward. Assess further in those who don't get to July without mistakes.
  • Treat underlying causes. Look for sources such as infection or electrolyte imbalances and address them if necessary.
  • Give an antipsychotic for severe symptoms. Lean toward a low dose of haloperidol, it has a relatively low risk of anticholinergic effects, sedation, and hypotension.
  • Consider an atypical (quetiapine, risperidone, etc) for patients who don't respond to haloperidol or to reduce the risk of extrapyramidal side effects. They seem to work as well as haloperidol.
  • Be careful about using ANY antipsychotic in patients with Parkinson's or Lewy body dementia. They can worsen cognition and cause neuroleptic malignant syndrome. Try a LOW dose of quetiapine if an antipsychotic is really needed.
  • Consider a benzodiazepine in special cases. Add a low dose of a short-acting benzo (lorazepam, etc) to an antipsychotic if needed for anxiety or agitation. But keep in mind that benzos can sometimes EXACERBATE delirium.
  • Give a benzo for delirium due to alcohol withdrawal. About 1 in 5 inpatients have alcohol dependence and benzos are first-line for both prevention and treatment of alcohol withdrawal.
  • Discontinue treatment when symptoms resolve to reduce adverse effects.

NPS-adv

References

  1. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306.
  2. Hatta K, Kishi Y, Wada K, et al. Preventive effects of ramelteon on delirium: a randomized placebo-controlled trial. JAMA Psychiatry. 2014;71(4):397-403.
  3. NICE guidance. Delirium: prevention, diagnosis and management in hospital and long-term care. https://www.nice.org.uk/guidance/cg103.
Abdelwahab Ward, BS Pharm, PharmD