Delirium medical therapy

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Delirium Microchapters


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Pratik Bahekar, MBBS [3] ; Vishal Khurana, M.B.B.S., M.D. [4]


Treatment of delirium involves two main strategies: first, treatment of the underlying presumed acute cause or causes, secondly, optimizing conditions of the brain. This involves ensuring that the patient with delirium has adequate oxygenation, hydration, nutrition, and normal levels of metabolites, so that drug effects are minimized, constipation treated, pain treated, and so on. Detection and management of mental stress are also very important. Therefore, the traditional concept that the treatment of delirium is treating the cause is not adequate. Common medications is used for delirium treatment include antipsychotic drugs, benzodiazepines, cholinestrase inhibitors, selective -a2 receptor agonist, melatonin based medications, ketamine.

Non-Pharmacological Treatments

  • Delirium is not a disease, but a syndrome (collection of symptoms) indicating dysfunction of the brain.
  • Treatment of delirium is achieved by treating the underlying dysfunction cause.
  • Non-pharmacological methods are the first measure in delirium unless there is severe agitation that places the person at risk of harming oneself or others.
  • Avoiding unnecessary movement
  • Avoidance of inter-and intra‑ward transfers
  • Continuity of care from caring staff
  • Avoidance of physical restraints
  • Involving family members
  • Having recognizable faces at the bedside
  • Sensory aids should be available and working where necessary
  • Maintenance or restoration of normal sleep patterns
  • Approach and handle gently
  • Avoid sudden and irritating noise (Pump alarms)
  • Careful management of bowel and bladder elimination
  • Having a means of orientation available (such as a clock and a calendar) may be sufficient in stabilizing the situation
  • Reassurance and explanation to the patient and carer of any procedures or treatment, using short simple sentences
  • If this is insufficient, verbal and non-verbal de-escalation techniques may be required to offer reassurances and calm the person experiencing delirium.[1]

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The T-A-DA Method (Tolerate, Anticipate, Don't Agitate)

Wandering and Rambling Speech

  • Wandering patients needs close observation insecure and closed surroundings.
  • Distract agitated wandering patient, relatives can prove helpful in curtailing agitation.
  • If the patient is agitated, rule out common stressors such as pain, thirst, need for toilet.
  • It is not advisable to agree with rambling talk, instead one may follow the following strategies:
  1. Acknowledge the feelings expressed ‑ ignore the content
  2. Change the subject
  3. Tactfully disagree (if the topic is not sensitive)


  • Physical restraints are often used as a last resort with patients in a severe delirium.
  • Restraint use should be avoided as it can increase agitation and risk of injury.[5]
  • In order to avoid the use of restraints some patients may require constant supervision.
  • Local laws on restrains must be well known to care providers.
  • If non-pharmacological techniques fail, or if de-escalation techniques are inappropriate, only then pharmacological treatment is indicated.

Medical Therapy

Dose of Haloperidol
Geriatric population, and seriously ill patients 0.25 - 0.50mg four hourly
Healthier patients 2mg - 3mg per day
Very agitated patients 5mg - 10mg per hour iv
  • Haloperidol can be administered orally, intramuscularly, or intravenously.
  • IV route can reduce extrapyramidal side effects.
  • Continuous IV infusions can be given instead of multiple IV bolus doses (haloperidol bolus, 10 mg i.v., followed by continuous intravenous infusion of 5–10 mg/hour).
  • Droperidol has quick sedative effect in agitated patients with less respiratory or cardiac side effects. [11]
  • Antipsychotics are usually given for a short period of time approximately 1 week.[12]
  • Long-acting olanzapine injection, sometimes may cause delirium, this is known as a post-injection delirium sedation syndrome. [13]


Indication for prescribing sedatives in delirium:[18][19]

  1. To conduct required diagnostic procedures or to deliver treatment
  2. If the patient is a danger to others or themselves
  3. Highly agitated or hallucinating patient
  1. Parkinson's disease
  2. Neuroleptic malignant syndrome
  3. Dementia with Lewy bodies


Morphine and Paralysis


Individual and Family Psychological and Social Characteristics


  1. The patient should be discharged after consulting all relevant disciplines in the hospital and outpatient care providers.
  2. Housing and living issues like washing, dressing, medication must be sorted out before the patient is relieved from the hospital.
  3. Cognitive and functional status (e.g. using standardized tools such as AMT and Barthel Index) must be accessed before discharge
  4. Discharge summaries must be complete and descriptive.

Follow up

Unique Challenges in the Treatment of Delirium

Side effects of pharmacotherapy


'Bezodiazepines': Can cause behavioral dis-inhibition, amnesia, ataxia, respiratory depression, physical dependence, rebound insomnia, withdrawal reactions, and delirium.

Anticholinergics Causes dizziness, blurred vision, urinary retention, constipation, confusion, and delirium.[27]

Education and Reassurement

Post Delirium Psychiatric Management


  • Because of transient impairment in cognition, orientation and other higher functions, the patient may not be able to provide consent or there can be impairment of competency.
  • Delirium itself does not make the patient incompetent by law.
  • Emergency cases can be treated without obtaining consent however non emergency cases pose an ethical dilemmas.


Treatment of Reversible Causes of Delirium

Identify reversible causes of delirium and treat them promptly: Suspected Hypoglycemia

Hypoxia or anoxia (secondary to pulmonary disease, cardiac problems, hypotension, severe anemia, CO poisoning)


Severe hypertension

Alcohol or sedative withdrawal

Wernicke’s encephalopathy:

  • Thiamine hydrochloride i.v. and followed by daily oral or IM doses

Anticholinergic delirium:[32]


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