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Back to Module 6: Anxiety, Delirium, Depression Assessment and Management of Delirium

Assessment of Delirium
Management of Delirium

• General Considerations
• Neuroleptics
• Atypical Neuroleptics
• Management of Terminal Delirium
• Evaluating Treatment

Assessment of Delirium in Advanced Illness

• The diagnosis needs to be distinguished from:

• anxiety,
• depression and
• dementia (which is slowly progressive, usually irreversible, and commonly associated with unaltered consciousness until very late in its course)

• A tool such as the Folstein mini-mental status exam can be used for more definitive assessments

• To order a copy of the Mini Mental Status Examination from the publisher of the test see: http://www.minimental.com

• Also, see http://www.nia.nih.gov/health/pubs/clinicians-handbook/test.pdf for a downloadable copy of the Mini Mental Status Examination

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Management of Delirium in Advanced Illness

General Considerations in the Treatment of Delirium

• Management of delirium begins by first evaluating the benefits vs burdens of seeking and treating reversible causes

• For some patients, it may be most efficacious to try to treat the delirium rather than search for the underlying cause

• In all cases, it makes sense to review the medication list and try to relate changes in medication to the onset of the symptoms

• If medications are felt to be responsible, consider removing those that are nonessential

• General treatment measures are frequently beneficial

• If the patient must be in the hospital, try to ensure that family and caregivers are present as much as they can be


• Reduce excessive stimulation, and regularly orient and assure the patient of his or her safety regularly


• Familiar surroundings are more likely to be calming. If possible, discharge the patient home with the necessary supports in place, e.g., home hospice

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Neuroleptics

• If medications are needed, neuroleptics may be helpful

• Monitor for extrapyramidal adverse effects, e.g., dystonia or akathisia

haloperidol

• 0.5–1 mg po, iv, sc q 1h prn, titrate until settled, then q 12 to q 6h to maintain


• Total daily doses of 1–20 mg or more may be needed


• Less sedating than chlorpromazine

chlorpromazine

• 10–25 mg po/iv q 4–6h for sedating neuroleptic


• Low doses are ideal for nighttime sedation, especially with day-night reversal, and/or in the elderly


• Delirium may worsen in some patients because of chlorpromazine’s anticholinergic effect


• It also lowers the seizure threshold

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Atypical Neuroleptics

• Cause less dystonia and akathisia than typical neuroleptics

• Risperidone may be better in demented or agitated delirium

• risperidone 0.5–1 mg q 12 and titrate

• Sedating atypical neuroleptics (e.g., olanzepine, quetiapine) are alternatives to chlorpromazine, though they have been less extensively used or studied in this population

• olanzepine 2.5–7.5 mg po q 12h
• quetiapine 75–100 mg po q 12h

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Management of Terminal Delirium

• Management is focused on:

• Symptomatic control
• Relief of the distress of both patient and family

• Benzodiazepines or sedating neuroleptics are usually effective at settling the patient (see Module 12: Last Hours of Living)

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Evaluating Treatment

• Patients on medication for delirium should be monitored carefully and regular meetings arranged to discuss their progress

• If there is a negligible or only partial response:

• Reevaluate the diagnosis
• Consider adjusting the dosage
• Try a different medication
• Inquire of family members and caregivers about adherence to medication

• If delirium persists, seek advice from, or refer to, a specialist

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