Confusion/Delirium

Principle: Always manage symptoms of delirium as well as consider reversible causes

If life expectancy is less than a few days, managing symptoms only may be appropriate

The presence of dementia increases the risk of delirium by 5–10 times.

Reversible causes

C=constipation
H=hypovolemia, hypoglycemia, hypercalcemia
I=infection
M=medications
B=bladder outlet obstruction/retention
O=oxygen deficiency
P=pain

Medications

Review and stop anticholinergics and benzodiazepines (unless alcohol withdrawal).

Neuroleptics for delirium treat only psychosis and agitation. Unlikely to help in hypoactive delirium.

Staffing determines whether medications needed in non-agitated delirium.

Mild-moderate agitated delirium

Haloperidol

  • 2-5mg po/sc q8-12hrs + breakthrough does q1hr
  • frail older adult: 0.5-2mg po/sc q12hrs + breakthrough dose q1hr

Quetiapine

First choice in Parkinson’s/Lewy Body dementia

12.5mg-25mg orally once daily or BID with prn dose BID

Methotrimeprazine

5mg – 12.5mg orally once daily or BID regularly with prn q1hour prn

Talk tip: To family: “Delirium is common in people with serious illness. We always try to reduce the distress and if possible reverse the delirium.”

If close to end-of-life, may not be able to reverse, but always treat symptoms.

Agitated delirium

Midazolam severe delirium/agitation is an emergency, consult palliative care

  • 2.5-10mg sc q20 mins to settle
  • frail older adults: 1.25-5mg sc q20 mins to settle
  • For agitated terminal delirium: midazolam infusion 2.5mg-10mg per hour by continuous infusion pump. Bolus of 2.5-5mg q15 minutes prn for breakthrough agitation. Titrate infusion to have patient looking like peaceful sleeping.

Methotrimeprazine

  • 5-10mg – 25mg sc q6hrs po/sc + q1hr breakthrough dose
  • frail older adult: 2.5-5mg q6hrs po/sc + q1hr breakthrough dose

Consider: dexmedetomedine – Consult PC

Talk tip: To family ”Delirium is common in people with serious illness. We always manage the symptoms of agitation and distress and if possible, reverse the delirium.”

If close to end-of-life, may not be able to reverse, but always treat symptoms.

Other therapies

  • limit activities and noise around patient
  • use natural light to orient patient to day/night time
  • familiar/calm people with the patient
  • avoid physical restraints