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