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

Reversible causes

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

Drugs

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

Non-agitated delirium

Haloperidol

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

Methotrimeprazine

  • 5-50mg po/sc at hs depending on need for sedation to sleep
  • frail older adult: 2.5-25mg po/sc at hs
  • note: quetiapine less likely to cause tardive dyskinesia in Parkinson’s patients

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, contact us)

  • 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

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

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