Pharmacological management of delirium in adults

Approach to pharmacological management in adults

Note: Drugs are not required to manage most patients with delirium.

If cause(s) of delirium are promptly addressed and nonpharmacological measures instigated (see Principles of managing delirium), drugs are not required for most patients.

Approach to using a psychotropic to manage delirium in an adult summarises the approach to using a drug to manage delirium in an adult.

No drug is approved by the Therapeutic Goods Administration (TGA) to treat delirium. Although antipsychotics are commonly used to manage delirium, high-quality evidence demonstrating effectiveness is unavailable. Systematic reviews of low-quality data suggest that antipsychotics do not reduce mortality, length of hospital stay, or delirium severity or duration, and do not improve cognitive function. Additionally, antipsychotics have significant adverse effects, including aggravation of delirium.

Nevertheless, clinical experience indicates that it may be reasonable to use an antipsychotic (combined with the other management strategies) if an adult with delirium is significantly distressed, or considered a threat to themselves or others—see Antipsychotic regimens for delirium.

Avoid using benzodiazepines for delirium, except when delirium is related to alcohol or benzodiazepine withdrawal, or seizures. Benzodiazepines increase delirium risk and adverse effects are common.

Figure 1. Approach to using a psychotropic to manage delirium in an adult

Avoid using a psychotropic to manage delirium—address its cause(s) and use nonpharmacological interventions first.

If a psychotropic is required because the patient is significantly distressed, or considered a threat to themselves or others, administer an antipsychotic orally, if possible [NB1].

A single dose of an antipsychotic is usually adequate.

Avoid using benzodiazepines except for delirium caused by alcohol or benzodiazepine withdrawal, or seizures.

If a psychotropic is used, still address the cause(s) of delirium and use nonpharmacological interventions.

Monitor the patient’s vital signs during and after administering an antipsychotic.

Avoid using ‘as needed’ (prn) psychotropic orders. If these cannot be avoided, clearly specify both the indication for administration and the maximum dose per 24 hours—review the patient and the use of the ‘as needed’ psychotropic daily.

Keep a record of drugs given to the patient and ensure this record accompanies the patient if they are moved to another location.

Note: NB1: For mechanically-ventilated adults with hyperactive delirium in an intensive care setting, dexmedetomidine may be considered—it has been associated with a shorter duration of mechanical ventilation and delirium. Dexmedetomidine does not appear to reduce number of days with delirium‐or coma, use of physical restraint, length of stay and mortality, or improve long‐term cognitive outcomes.

If the cause of the delirium is unknown and could be caused by alcohol withdrawal, consider starting thiamine; see regimen here.

Antipsychotic regimens for delirium

Despite the limitations of antipsychotic therapy, consider using the regimens below for an adult with delirium if they are significantly distressed, or considered a threat to themselves or others, and addressing the cause(s) of delirium and using nonpharmacological measures have not calmed them.

For adults with delirium who do not have Parkinson disease or dementia with Lewy bodies, use:

1 haloperidol 0.5 mg orally, as a single dose¹; 1 mg may be required for younger patients delirium haloperidol haloperidol haloperidol

OR

1 olanzapine 1.25 to 2.5 mg orally, as a single dose; 5 mg may be required for younger patients delirium olanzapine olanzapine olanzapine

OR

1 risperidone 0.5 mg orally, as a single dose; 1 mg may be required for younger patients. delirium risperidone risperidone risperidone

Haloperidol (in particular) and olanzapine and risperidone can aggravate motor features in Parkinson disease or dementia with Lewy bodies.

For adults with delirium who have Parkinson disease or dementia with Lewy bodies, use²:

quetiapine 25 mg orally, as a single dose. delirium quetiapine quetiapine quetiapine

If oral administration is not possible for adults with delirium who do not have Parkinson disease or dementia with Lewy bodies, use:

1 haloperidol 0.5 mg intramuscularly, as a single dose³; 1 mg may be required for younger patients haloperidol haloperidol haloperidol

OR

1 olanzapine 2.5 mg intramuscularly, as a single dose; 5 mg may be required for younger patients. olanzapine olanzapine olanzapine

If oral administration is not possible for adults with delirium who have Parkinson disease or dementia with Lewy bodies, seek expert advice.

Note: A single dose of an antipsychotic is usually adequate to manage hyperactive delirium.

A single dose of an antipsychotic is usually adequate to manage hyperactive delirium. The onset of action for the above antipsychotics can be delayed by 30 to 60 minutes—do not give a second dose for at least 30 minutes. Antipsychotics are slowly eliminated and repeat doses can have cumulative effects. If further doses are required, review the diagnosis and management plan. In particular, optimise nonpharmacological measures (see Principles of managing delirium in adults). A short course (eg 48 to 72 hours) of regular low-dose antipsychotic therapy may be appropriate for patients who initially respond to an antipsychotic but experience persistent severe distress—stop the antipsychotic as soon as possible. Ongoing delirium can be an antipsychotic adverse effect.

After antipsychotic administration, gently encourage the patient to walk around a safe space. Minimise threatening stimuli and ensure staff maintain a respectful distance to reduce the risk of exacerbating the patient’s agitation.

Monitor the patient’s vital signs during and after administering the antipsychotic.

Intravenous therapy is rarely required for patients with delirium and should be avoided. For advice on managing a patient who poses an immediate threat to themselves or others, and requires immediate sedation, see here for adults and here for older people.

¹ Haloperidol has a higher incidence of extrapyramidal adverse effects than olanzapine and risperidone; however, when it is used for short-term treatment of delirium, these effects are usually limited.Return

² Dopaminergic drugs often precipitate delirium. Review and rationalise dopaminergic therapy. Polypharmacy increases the risk of adverse effects. For further information on neuropsychiatric symptoms in Parkinson disease, see here.Return

³ Haloperidol has a higher incidence of extrapyramidal adverse effects than olanzapine; however, when it is used for short-term treatment of delirium, these effects are usually limited.Return