Treating Delirium
The treatment of delirium is the identification and treatment of the underlying cause while maintaining safety and comfort.
Who Gets Admitted?
Not all patients with delirium need to be admitted, but safe discharge requires:
- The delirium to be identified
- AND a single, clear, and reversible etiology to be identified
- AND the presence and understanding of family or friends who can observe the patient until the delirium resolves.
Examples of Safe Discharge:
1Someone with a new lobar pneumonia, able to tolerate oral antibiotics, and returning to a long-term care home.
2Someone with an anticholinergic delirium from extra Gravol© with a competent caregiver.
3Someone with a UTI or fecal impaction or urinary retention that have now been treated and a caregiver at home who feels comfortable managing the patient.
Treating the Symptoms of Delirium
Patients, families and ED staff are most bothered by the symptoms of delirium – usually the agitation. These agitative symptoms can be treated in two ways:
Click on the titles below to learn more.
Pharmacologic Treatment
Use pharmacologic management for severe agitation that prevents therapy or puts the patient or others at risk.
Haloperidol
- 0.5mg-1.0mg PO/IM/SC/IV q30minutes prn – reassess after 3 doses. Try PO route first.
Other Medications
Respiridone, Olanzapine may also be useful, but are more difficult to dose, have a longer half-life, and are not always available in the ED.
Non-Pharmacologic Treatment
- avoid/remove restraints including catheters and non-essential monitor leads
- promote mobility
- allow/encourage food and drink
- address bowel and bladder function
- increase sensory stimulation (hearing aid, eye glasses)
- enhance orientation and familiar faces (family)
- minimize medication changes (i.e. make sure they’re getting what they get at home)
- manage pain.
Haloperidol — the Wonder Drug!
- Commonly available
- High potency
- Limited anti-cholinergic effects
- Available in both oral and parenteral forms
- However it is anti-dopaminergic so it may cause problems in Parkinsonian patients because of increased extra pyramidal symptom.
Important Note
Benzodiazepines are NOT a good choice except for alcohol or sedative withdrawals: Benzodiazepines may worsen confusion, behavioral disinhibition, amnesia, ataxia, etc.
Discussion: Treating Delirium
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I agree
I like the non pharmacologic measure of removing the catheter unless the patient really needs it. Good to know this restrains the client.
Giodon is gold for acute psychiatric episodes
Appropriate treatment speeds up early discharge and hopefully delays further dementia
Haloperidol says hello
We love haloperidol in my ER
yes, and now i have a reason to give my pharmacist the next time she tries to refuse giving a ‘typical’ AP and trying to get me to give like 1/2 a whiff of PO atypical med to an acutely aggressively agitated 200 lb older man
agree
good.
yes
ok
agree with above
One of the psychiatrists that I work with likes low dose trazodone for agitation in the elderly.
interesting!
good review on medications
good
ok
so good to minimize restraints such as cardiac monitors and catheters if possible
ok
ok
Speaking with the patient and trying to understand their complaints goes a long way
ok
ok
good information
haloperidol
ok
you treat by gaining there trust, keep them focused on the treatment plan, and avoid escalation. If required then treat with pharmacology and avoiding benzos. Have family participate in the treatment if that makes the patient cooperate and more tranquil.
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good info
avoid benzos
Agree
Agreed
yes
nice
yes
good
yes
the importance of knowing the patient’s environment
good
yes that’s it
.
.
..
important to treat the underlying cause
.
agreed
sometimes treating the underlying issue resolves the delirium (such as sepsis).
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Very helpful regarding medications. What if you cant identify the delirium? What if it is the new normal? Is that possible?
Emphasizes medication restraints
–
we used diazepam earlier.
it is good to know that Haloperidol does such wonders
Helpful
Haldol is frequently used in the ED setting
ok
Agree with trying nonpharmacologic first, but, if necessary, pharmacology is helpful.
I find sometimes we wait to long before going to medications
yes
Very helpful information.
Agree with the comment on trying non-pharmacological first.
helpful
yes
Agree. Benzos can be overused.
good
HELPFUL
Good summary
pretty good direction – short and clear
helpful
slow talking, sit down with patient
very helpful
great info
Continuing education.
helpful
Muy buen tema para tratar los paciente con delirio ,porque siempre constituyen elementos estresantes para la familia ,las enfermeras de turno y los médicos
This message has been brought to you by….Haldol©.
Ok, this page was in fact helpful.
Agee
great information. useful in determining dispo of the pt
This is helpful
this is helpful
very helpful
continuous learning
Family education programs and nursing home continuing education.
very informative to know the drug of choice as well as the drug to watch out for
same here, great information
See a lot of haloperidol use with elderly patients, sometimes wonder if it is prophylactic for delirium since the prn comments match up well with AIDA
good post and information, seen mostly Haloperidol given PO/ or IM and sometime either with Olanzipine or Rispiridone.
Prefer a non-pharmacologic method if possible, however, many families cannot be bothered (i.e. have to work in am, can’t sit with them, etc.). See lots of NP’s & MD’s order BZD for pt. Just a LOT more problems with it. Can’t say see much better with haldol either though.
Very helpful
good
curious how to delineate between the use of Haldol for the “distressing symptoms” of agitation vs. the mortality increase found in studies. I would not call it a “wonder drug” for delirium, and have heard anecdotal stories of the elderly dying of dysrhythmias from haldol. I’ve found it’s much more helpful to invoke the family &/or a sitter to assist with re-orientation. Haldol should only be used as a last resort for safety of the patient/staff
I agree. I was very surprised to note that it was called a wonder drug as so many studies have shown an increase in mortality. Certainly it is a better medication than benzos, but I agree that we must try other non-pharmacological routes first.
treatment of agitation is hard in delirium. No great answers.
haloperidol is great though usually need to cut back dosing and use as stand-alone instead of the B52 (Benadryl, 5 Haldol, 2 Ativan) cocktail used in younger agitated patients.
If you are safely able to send them home with proper supports that understand the treatment process and when/if they should return the patient to the hospital it is better for the patient to be in a familiar environment. Unfortunately this not always the case.
I find we do not use haloperidol very often for geriatrics where I work
Also helpful
helpful
haldol contraindicated in lewy body dementia
Was very helpful to know
good information. Thank you
good info.
great information
Safety very important during the discharge,
sadly, we have patients whose family leaves to only return at discharge 3 days later.
Great information
very interesting
Reduce stimulation from monitoring, noise, bright lights. Fix hungry, thirsty, toilet issue if possible. Droperidol if those don’t work.
I like the dosing recommendations for Haldol.
Agreed!
excellent info
Haldol wonder drug indeed
Very interesting discussions above. Good warning about benzos.
Good to consider omitting benzo as treatment of delerium dut to alcohol or sedative withdrawal.
Haldol can be useful, but it’s always great to see improvement with medical treatment of cause.
good info on BDZ and its avoidance
if patient only needs it we do prescribe meds.
Since i am not a Dr perscribing meds it is nice to hear sometimes employing as many non pharmaceutical therapies can often help the pt.
recent systematic review in the JAGS suggest that neuroleptics have very benefit in delirium especially with reducing duration of delirium or reducing LOS. Non pharm is the way to go, but takes experience and patience.
haloperidol the wonder drug
Start with non pharmacological treatment and then give medication such as Haloperidol in low dose. We must remember that hypoactive delirium is more common than hyperactive delirium.
Hypoactive delirium also benefits from all of those non-pharmacologic strategies — promote comfort (bowel/bladder, food, drink, warmth, mobility, orientation).
It is always concerning and frustrating when medications for sedation can have such significant downsides and that their usefulness is often not satisfactory.
Geriatrics seems to favour quetiapine at my institution, although I don’t think this is evidence based. I like haloperidol but often start with even smaller doses (0.25).
The situation I find most difficult is the Parkinson’s patient with agitated delirium.
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Is there a role for atypical antipsychotics with potentially better side-effect profiles? Or is the anticholinergic effects of the antypicals make them undesirable in delirium management?
There’s definitely a role, but usually they are limited by available routes of administration. You can use atypicals PO standing, with a PRN IM/IV antipsychotic – usually haldol.
Interestingly, we were advised by a geriatrican to ‘snow’ a patient with versed for 24hours and let him ‘sleep off’ the delirium caused by increasing his fentanyl patch. The patient had experienced hallucinations and insomnia, frequently yelling out and crying through the night, but after 24hs of versed induced sleep and adjustments to his fentanyl patch during that phase, he awakened remarkably alert and rested.
A very unusual approach which I wouldn’t recommend building into standard practice. I’m glad it worked (actually, you didn’t say that it did work!) In general benzos are not a helpful medication for the agitation associated with delirium and tend to have a very long half-life because they are so lipophilic and old people have more fat than water. A antipsychotic like haloperidol might have been a reasonable alternative.
I did not know that Haldol what a safe drug to use in the Geri population, super helpful information to use in my practice
Make sure they don’t have Lewy bodies dementia it’s not the drug for that population it can cause neuroleptic syndrome
Patience and thoughtful trouble shooting make a huge difference. Empathy is too often forgotten when dealing with the acutely agitated patient.
Did not realize that Haldol was considered safe in delirium patients.
Under non-pharmacologic treatments of agitation it states that restraints, including catheters, should be removed. The indications for foley catheters are few and very specific. Dementia/delirium/immobility are not indications catheters and only increase morbidity and mortality.
Calling in family members to the bedside often settles the patient down
Remove what annoys the pt
Early identification is key.
Safety should be paramount in the decision making. For staff, patient and dept
Allow the Pt to remove what is annoying.
And I think we need to be careful about what we’re calling “agitation.” Sometimes “agitation” just means caregivers are getting tired of being asked the same question over and over!! I like the formulation of “preventing care.” — Couldn’t agree more sounds like several long term care facilities.
Agree
nice to know
so…treating delirium is essentially recognizing delirium and fixing everything that isn’t delirium? um….ok.
What’s the question?
Ketamine!
ok
.
Good examples of patients that can be sent home, illustrating that the decision to discharge is multifaceted: medical condition; social setting, safety netting; follow up.
Would love to see haloperidol in Pre-hospital care.
no restrictions, support at home
Behavioural mgmt with non pharm is often difficult to manage
evaluate social and family care and think in other terrapins non farmacologic treatment
education to family or carers as well as identifying risk factors to avoid complications
Discard in patients who go for your home that there are risk factors that can complicate
Important to identify which patients can be sent home
🙂
There seems to be a lot of variability in what is recommended to treat acute agitation.
In Australia (where I practice), guideline is droperidol if IM sedation required. Otherwise first line therapy for emergency sedation is PO lorazepam in 65.
I agree there is a lot of variation in practice — necessarily because of the wide range of clinical scenarios. I think a valuable distinction to make is between medication to “decrease agitation” and to “produce sedation” — which are close but subtly different. The anti-psychotics (of which your droperidol is an example, though not available in NA) are probably more helpful at reducing some of the psychotic/delusional symptoms which may well be driving the agitation in delirium. The benzos will be helpful if the agitation is adrenergically mediated as one sees in withdrawal syndromes — but run the risk in other deliriums of producing merely a drowsy, sedated, still delusional, and agitated old person. And it is absolutely true that if you work through ALL the non-pharmacological options, it is quite rare to need meds at all.
Non-pharmacological treatment will be good same , old people takes a lot of med, and stomach ?!
This is helpful.
haldol is good, although we rarely give PO
haldol
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Generally I find HAldol safe although I have seen a situation where a pt reacted poorly to it and their mentation never fully returned to their baseline
Haldol is usually effective, as well as hydration, mobility, rest, decreased sensory stimuli. Least restraints policy requires more promotion.
What is Pieces?
Haldol is commonly used, other meds may be considered in certain cases + non phamacological measures.
I really like using the PIECES method as well
if the patient is at harm then haldol is often the only choice, one on one care is the best choice but it comes at an expense of $15-20/ hr that we can’t seem to afford.
In my experience, when pharmacologic treatment is required, Haldol is very effective for severe agitation but many practitioners order Ativan which quite often worsen the pt’s state.
Admission is usually not the best choice (unless home based support is unavailable)
Hospital associated morbidity – common factors
• restraints including catheters and non-essential monitor leads
• restricted mobility
•restrictions on food and drink
•lack of sensory stimulation (hearing aid, eye glasses)
•multiple medication changes (i.e. make sure they’re getting what they get at home)
•failure to manage pain.
(does this list look familiar?)
the Canadian Coalition for seniors mental health has a nifty pocket guide to delirium diagnosis and treatment. Delirium is a medical emergency Try and institute PIECES first then minimal medical restraints
You’ll find that “nifty pocket guide” is in the Related Resources page at the end of this module which you can download directly from here! It’s excellent.
Liquid risperidone (1mg/ml) is very useful in treating frail and vulnerable seniors the community as doses can be titrated down to as low as 0.1mg
Getting them home – if safe to do so – if preferable to the floor because the change in environment (not to mention the lack of sleep on the always noisy and busy floor) makes the agitation worse (and someone is always trying to give them more meds to “settle” them down.
We should give non-pharmacological treatment a try if it is safe and pt is not agitated.
it is preferable that as quiet an environment and interactive observation are preferable to physical restraint or chemical ones, though it is difficult to achieve in er
I find that often just taking off all the monitoring leads (which no one is looking at anyhow!) allows the person to settle down.
And I think we need to be careful about what we’re calling “agitation.” Sometimes “agitation” just means caregivers are getting tired of being asked the same question over and over!! I like the formulation of “preventing care.”