Delirium medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Pratik Bahekar, MBBS [2] ; Vishal Khurana, M.B.B.S., M.D. [3]

Overview

Treatment of delirium involves two main strategies: first, treatment of the underlying presumed acute cause or causes; secondly, optimizing conditions of the brain. This involves ensuring that the patient with delirium has adequate oxygenation, hydration, nutrition, and normal levels of metabolites, so 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. 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 is also very important.

Non-Pharmacological Treatments

  • Delirium is not a disease, but a syndrome (collection of symptoms) indicating dysfunction of the brain.
  • Treatment of delirium is achieved by treating the underlying dysfunction cause.
  • Non-pharmacological methods 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
  • Avoidance of inter-and intra‑ward transfers
  • Continuity of care from caring staff
  • Avoidance of physical restraints
  • Involving family members
  • Having recognizable faces at the bedside
  • Sensory aids should be available and working where necessary
  • Maintenance or restoration of normal sleep patterns
  • Approach and handle gently
  • Avoid sudden and irritating noise (Pump alarms)
  • Careful management of bowel and bladder elimination
  • Having a means of orientation available (such as a clock and a calendar) may be sufficient in stabilizing the situation
  • Reassurance and explanation to the patient and carer of any procedures or treatment, using short simple sentences
  • If this is insufficient, verbal and non-verbal de-escalation techniques may be required to offer reassurances and calm the person experiencing delirium.[1]

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The T-A-DA Method (Tolerate, Anticipate, Don't Agitate)

Wandering and Rambling Speech

  • Wandering patients needs close observation insecure and closed surroundings.
  • Distract agitated wandering [[patient], relatives can prove helpful in curtailing agitation.
  • If the patient is agitated, rule out common stressors such as pain, thirst, need for toilet.
  • It is not advisable to agree with rambling talk, instead one may follow the following strategies:
  1. Acknowledge the feelings expressed ‑ ignore the content
  2. Change the subject
  3. Tactfully disagree (if the topic is not sensitive)

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.[6]
  • In order to avoid the use of restraints some patients may require constant supervision.
  • Local laws on restrains must be well known to care providers.
  • If non-pharmacological techniques fail, or if de-escalation techniques are inappropriate, only then pharmacological treatment is indicated.

Medical Therapy

Pharmacotherapy

Antipsychotics
Dose of Haloperidol
Geriatric population, and seriously ill patients 0.25 - 0.50mg four hourly
Healthier patients 2mg - 3mg per day
Very agitated patients 5mg - 10mg per hour iv

Sedatives

Indication for prescribing sedatives in delirium:

  1. To conduct required diagnostic procedures or to deliver treatment
  2. If the patient is a danger to others or themselves
  3. Highly agitated or hallucinating patient
  1. Parkinson's disease
  2. Neuroleptic malignant syndrome
  3. Dementia with Lewy bodies

Cholinergics

Morphine and Paralysis

Antidepressants

  • The antidepressant trazodone is occasionally used in the treatment of delirium, but it carries a risk of over-sedation, and its use has not been well studied.[17]

List of Commonly Prescribed Medicines Attributing to Delirium

Reversible Causes of Delirium

Identify reversible causes of delirium and treat them promptly: Hypoglycemia or is Suspected

Hypoxia or anoxia (secondary to pulmonary compromise, cardiac problems, hypotension, severe anemia, CO poisoning)

Hyperthermia

Severe hypertension

Alcohol or sedative withdrawal

Wernicke’s encephalopathy:

  • Thiamine hydrochloride i.v. and followed by daily oral or IM doses

Anticholinergic delirium:

Individual and Family Psychological and Social Characteristics

Psychodynamic issues, personality variables, and sociocultural environment are helpful in the management of specific anxieties and reaction patterns.

Discharge

  1. The patient should be discharged after consulting all relevant disciplines in the hospital and outpatient care providers.
  2. Housing and living issues like washing, dressing, medication must be sorted out before the patient is relieved from the hospital.
  3. Cognitive and functional status (e.g. using standardized tools such as AMT and Barthel Index) must be accessed before discharge
  4. Discharge summaries must be complete and descriptive.

Follow up

Unique Challenges in the Treatment of Delirium

Side effects of pharmacotherapy

Antipsychotics:ECG monitoring is required to calibrate QTc interval. Cardiology consult should be done if QTc interval is more than 450msec or it is greater than 25% baseline. Dose adjustment or discontinuation of antipsychotic medication may be warranted. Haloperidol has can cause sedation and hypotension. Lowering of the seizure threshold, galactorrhea, elevations in liver enzyme levels, inhibition of leukopoiesis, neuroleptic malignant syndrome, and withdrawal movement disorders are rare side effects of antipsychotic medication.

'Bezodiazepines': Can cause behavioral dis-inhibition, amnesia, ataxia, respiratory depression, physical dependence, rebound insomnia, withdrawal reactions, and delirium. Adolescents and pediatric may suffer from disinhibition reactions, emotional lability, increased anxiety, hallucinations, aggression, insomnia, euphoria, and in-coordination.

Anticholinergics Causes bradycardia, nausea, vomiting, salivation, and increased gastrointestinal acid. Physostigmine can cause seizures. Tacrine can cause liver function abnormalities.[8]

Education and Reassurement

  • It is important for psychiatrist help patient understand symptoms of delirium, by explaining transient nature of delirium can help patients and their families in coping.
  • As delirium is accompanied by behavioral changes, sometimes physicians and nursing staff may overlook the underlying medical condition responsible for delirium, therefore it is an important task for a psychiatrist to educate medical care provider about delirium.

Post Delirium Psychiatric Management

  • Post recovery patients may remember their experiences during delirium. This can cause significant distress in the patients. Symptoms may range from have vivid, frightening recollections.
  • Reassurance and explanation of condition can ease some stress.
  • Standard psychiatric interventions utilized following traumatic experiences should be used.
  • Psychotherapy can be helpful relieving anxiety, guilt, anger, depression, or other emotional states.

Competency

Because of transient impairment in cognition, orientation and other higher functions, patient may not be able to provide consent or there can be impairment of competency. Delirium itself does not make patient incompetent by law. Emergency cases can be treated without obtaining consent however non emergency cases pose an ethical dilemmas.

Elderly

Antipsychotic drugs can cause serious side effects in the geriatric population. Even though antipsychotic medications are prescribed for shorter duration of time in delirium, it caution must me practiced. Serious side effect tends to occur within 30 days of initiation of the treatment, serious side effects include,

  • Extra pyramidal side effects
  • Falls
  • Hip fracture, are few events which are severe enough to warrant an acute hospital admission. It may also cause death. Serious side effects are more frequent and likely in patients receiving conventional antipsychotic drugs than atypical antipsychotic medicines. Antipsychotics are 1 of the 3 offending medicines that require acute hospitalization in nursing group population.[19]

References

  1. "Delirium".
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  3. "Matching the Environment to Patients with Delirium: Lessons Learned from the Delirium Room, a Restraint‐Free Environment for Older Hospitalized Adults with Delirium - Flaherty -2011 - Journal of the American Geriatrics Society - Wiley Online Library".
  4. "Delirium".
  5. Flaherty, J. (2011). "Matching the Environment to Patients with Delirium: Lessons Learned from the Delirium Room, a Restraint-Free Environment for Older Hospitalized Adults with Delirium". Journal of the American Geriatrics Society. 59: 295–300. doi:10.1111/j.1532-5415.2011.03678.x. Unknown parameter |coauthors= ignored (help)
  6. Young, J. (2007). "Delirium in older people". British Medical Journal. 334 (7598): 842–846. doi:10.1136/bmj.39169.706574.AD. PMC 1853193. PMID 17446616. Unknown parameter |coauthors= ignored (help)
  7. Boley, Sean P.; Olives, Travis D.; Bangh, Stacey A.; Fahrner, Samuel; Cole, Jon B. (2018). "Physostigmine is superior to non-antidote therapy in the management of antimuscarinic delirium: a prospective study from a regional poison center". Clinical Toxicology. 57 (1): 50–55. doi:10.1080/15563650.2018.1485154. ISSN 1556-3650.
  8. 8.0 8.1 8.2 8.3 "Practice guideline for the treatment of pati... [Am J Psychiatry. 1999] - PubMed - NCBI".
  9. Taylor DM, Yap CY, Knott JC, Taylor SE, Phillips GA, Karro J; et al. (2016). "Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial". Ann Emerg Med. doi:10.1016/j.annemergmed.2016.07.033. PMID 27745766.
  10. Zareifopoulos N, Panayiotakopoulos G (November 2019). "Treatment Options for Acute Agitation in Psychiatric Patients: Theoretical and Empirical Evidence". Cureus. 11 (11): e6152. doi:10.7759/cureus.6152. PMC 6913952 Check |pmc= value (help). PMID 31890361.
  11. Girard TD, Exline MC, Carson SS, Hough CL, Rock P, Gong MN, Douglas IS, Malhotra A, Owens RL, Feinstein DJ, Khan B, Pisani MA, Hyzy RC, Schmidt GA, Schweickert WD, Hite RD, Bowton DL, Masica AL, Thompson JL, Chandrasekhar R, Pun BT, Strength C, Boehm LM, Jackson JC, Pandharipande PP, Brummel NE, Hughes CG, Patel MB, Stollings JL, Bernard GR, Dittus RS, Ely EW (December 2018). "Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness". N Engl J Med. 379 (26): 2506–2516. doi:10.1056/NEJMoa1808217. PMC 6364999. PMID 30346242.
  12. Jain R, Arun P, Sidana A, Sachdev A (2017). "Comparison of efficacy of haloperidol and olanzapine in the treatment of delirium". Indian J Psychiatry. 59 (4): 451–456. doi:10.4103/psychiatry.IndianJPsychiatry_59_17. PMC 5806324. PMID 29497187.
  13. Hatzakorzian, R.; Shan, W. Li Pi; Côté, A. V.; Schricker, T.; Backman, S. B. (2006). "The management of severe emergence agitation using droperidol". Anaesthesia. 61 (11): 1112–1115. doi:10.1111/j.1365-2044.2006.04791.x. ISSN 0003-2409.
  14. "http://www.nice.org.uk/nicemedia/live/13060/49909/49909.pdf" (PDF). External link in |title= (help)
  15. McDonnell DP, Detke HC, Bergstrom RF, Kothare P, Johnson J, Stickelmeyer M, Sanchez-Felix MV, Sorsaburu S, Mitchell MI (June 2010). "Post-injection delirium/sedation syndrome in patients with schizophrenia treated with olanzapine long-acting injection, II: investigations of mechanism". BMC Psychiatry. 10: 45. doi:10.1186/1471-244X-10-45. PMC 2895590. PMID 20537130.
  16. Lonergan E, Luxenberg J, Areosa Sastre A, Wyller TB (2009). Lonergan, Edmund, ed. "Benzodiazepines for delirium". Cochrane Database Syst Rev (1): CD006379. doi:10.1002/14651858.CD006379.pub2. PMID 19160280.
  17. "Delirium".
  18. "Delirium in older people". Text " BMJ " ignored (help)
  19. "Antipsychotic therapy and short-term serious... [Arch Intern Med. 2008] - PubMed - NCBI".

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