What is Delirium: management - Meaning and definition

Published by Roberto Wenk. Last updated date: March 18, 2019.

Delirium may be
- hyperactive (presenting with agitation, hyper arousal, and restlessness), or
- hypoactive (presenting with drowsiness, lethargy and reduced levels of arousal), or
- a mixed pattern in which the symptoms fluctuate between hyperactive and hypoactive.

Delirium is extremely common in palliative care patients. It becomes more frequent towards the end of life - it is a medical emergency, and the goals of care are
- to provide safety for the patient
- to identify the cause, and
- to treat the cause when possible or appropriate.

Nonpharmacologic management.
Reorientation techniques or memory cues such as a calendar, clocks, and family photos may be helpful. The environment should be stable, quiet, and well-lighted.
Family members and staff should explain proceedings at every opportunity, reinforce orientation, and reassure the patient. Support from a familiar nurse and family should be encouraged.
Sensory deficits should be corrected, if necessary, with eyeglasses and hearing aids.
Physical restraints should be avoided. Severely delirious patients benefit from constant observation (sitters), which may be cost effective for these patients and help avoid the use of physical restraints. These patients should never be left alone or unattended.

Pharmacological management.
It is imperative to start low and go slow and the medications are titrated to effect.
Haloperidol is most often recommended because it has fewer anticholinergic side effects, is less sedating, has fewer active metabolites, and rarely causes orthostatic hypotension or cardiovascular side effects.
Second-line atypical agents for treatment of delirium are olanzapine, risperidone, and quetiapine.
Benzodiazepines are not recommended for delirium in older adults because of the risk of rebound confusion, agitation, and risk for falls. These drugs can cause oversedation and exacerbate confusion.

Practice guideline for the treatment of patients with delirium

Adapted from Medscape Drugs & Diseases. Delirium: Opportunity for comfort in Palliative Care treatment & management. Internet. Available at http://www.medscape.com/viewarticle/770069_4. Accessed on February 15, 2016. To view the entire article and all other content on the Medscape Drugs & Diseases site, a free, one-time registration is required.

Published by Roberto Wenk. Last updated date: March 18, 2019.

Management of delirium comprises identification and wherever possible treatment of possible underlying cause(s):
- Medicines
- Organ failure
- Hypoxia
- Infection
- Hypercalcaemia
- Fluid or electrolyte disturbance
• Delirium is commonly caused by medicines and the patient’s current medicines should be reviewed before
pharmacological management is initiated.
• When treatment of the underlying cause(s) of delirium is not possible or unsuccessful, pharmacological management is necessary.
Causal treatment may not be indicated in patients with limited prognosis and pharmacological symptomatic therapy has to be initiated without delay.

- Haloperidol is considered as first choice therapy in the management of delirium during the terminal phases of disease.
- It has been shown to be effective in the management of both hyperactive and hypoactive delirium in adult patients during the terminal phases of disease. However, the amount of evidence is limited.
- In two controlled studies haloperidol was as effective as clopromazine or aripiprazol, but significantly more effective than lorazepam.
- Considering the lack of evidence from clinical trials, the recommendation for haloperidol is based on clinical expertise. Expert opinion strongly supports the use of haloperidol for treatment of delirium in adults.

Haloperidol
Recommended formulations:
Injection: 5 mg in 1‐ml ampoule.
Oral liquid: 2 mg/ml.
Solid oral dosage form: 0.5 mg; 2mg; 5 mg

Additional supporting information for this drug:
• Oral bioavailability of 60-70%
• Onset of action 10-15 minutes if given SC; >1 hour if given orally.
• The time to peak plasma concentration is 10-20 minutes subcutaneously and 30-40 minutes if given orally.
• Duration of action up to 24 hours, sometimes longer.
• It carries the risk of extrapyramidal side-effects. When compared with chlorpromazine, haloperidol has less effect on the cardiovascular system.
• It does not have any antimuscarinic properties
• It is widely available and at low cost

Despite the absence of good quality clinical trials, haloperidol is widely used in the management of delirium in palliative care.

Adapted from Radbruch L et al. Essential medicines in palliative care - An application for the 19th WHO Expert committee on the selection and use of essential medicines. Kindle Edition, 135 pages. Published June 5th 2013 by IAHPC Press. Available at https://www.amazon.com/Essential-Medicines-Palliative-Care-Application-ebook/dp/B00D7S2D0C

Delirium: management

Practice guideline for the treatment of patients with delirium

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