Download Trigger for Managing Delirium

CHAMP: Bedside Teaching
MANAGING AGITATED DELIRIUM
Andrea Bial MD
Teaching Trigger:
A hospitalized senior with delirium is agitated, although not a threat to self or others.
The team wants to give haldol now; the nurse wants an order for soft wrist restraints “just
in case” because the patient will be going to radiology later for a CT scan.
I.
Clinical Question:
What are the appropriate indicators and choices for medication use in delirium?
Teaching Points:
1. Pharmacologic Management
a. No RCT of treating delirium in hospitalized seniors.
b. Most recommendations are extrapolated from delirium in other patient
populations (cancer, AIDS, etc) or from agitation in dementia patients.
c. See Table 1 below.
TABLE 1: MEDICATIONS FOR THE TREATMENT OF DELIRIUM
DRUG
CATEGORY
Risperidone
Atypical
Antipsychotic
Min sedating;
less EPS
Olanzapine
Atypical
Antipsychotic
Min sedating;
less EPS
Quetiapine
Atypical
Antipsychotic
Min sedating;
less EPS;
better in PD?
DISADVANTAGES ↓ sz thrshld;
more EPS;
↑QT; ↑ risk
of Torsades
Take time to
work; no
evidence in
acute use
Same as
Risperidone
Same as
Risperidone
DOSE
0.25-0.5mg
po, IM, IV;
can repeat in
30 mins x1,
then q4h
21h (10-30h)
0.25-0.5mg
po bid
2.5-5mg po
qd
25mg po bid
20-30h
30h (21-54h)
6h
12h
Probably a
better choice
in acute
setting when
patient is
very agitated
Use the
atypicals
when
medication
needed but
not urgently
Same as
Risperidone
Same, except
use this if pt
has or is
suspected to
have PD
Do not use for
delirium except
in the case of
w/d or if
antipsychotics
cannot be used
ADVANTAGES
T1/2 AVG
(RANGE)
COMMENTS
II.
Haldol
Typical
Antipsychotic
Min sedating;
can be given
IM or IV (not
FDA-apprvd)
Lorazepam
Benzodiazepine
Useful in w/d;
no 1st-pass liver
effect; no renal
adjustment
necessary
Very sedating;
possible
disinhibition
effect; can
cause delirium
0.5-1mg po,
IM, IV q6-8h
Clinical Question:
What is the nonpharmacological management of delirium?
Teaching Points:
1. Background
a. As stated previously, you will often need to be treating the patient
while also evaluating the cause of his/her delirium.
b. Focus on reassurance, orientation, noise reduction, and mobilization of
the patient.
c. AVOID restraints (see below); use family members or request bedside
sitters.
2. Non-pharmacologic management/7 key areas:
a. Cognition: ensure orientation with correct date on orientation boards
and keeping drapes open during the day.
b. Sleep: minimize sleep deprivation by avoiding 2am blood draws; no
overnight VS or BS if can be avoided; orders meds for “when awake”
(e.g., nebs).
c. Mobility: OOB to chair asap; order PT/OT asap; avoid foley catheters
and restraints. See below.
d. Vision: assess whether or not patient uses (or needs) glasses, and if so,
attempt to get them; if N/A, post sign stating “Low vision.”
e. Hearing: assess whether or not the patient is hard of hearing and has
aids; if not, post sign stating “HOH; please speak loudly in front of
patient.”
f. Dehydration: ensure fluid intake (po is best) even if it means teammember sits with patient at mealtime to observe. Avoid the
accumulation of cans of nutrition supplements at the bedside.
g. Observation: ask family members to sit with patient or get sitter; move
patient closer to nurse’s station.
III.
Clinical Question:
What is the role of restraint use in the delirious older patient?
Teaching Points:
1. Avoid physical restraints whenever possible, including “unofficial” restraints such
as using a bed-sheet to tie a patient down.
2. Restraints increase the risk of falls, injury, and delirium.
3. If needed for emergent situation (patient is a threat to self or others), use for the
shortest duration possible with frequent re-evaluations for need and possibility of
discontinuing.