Management of delirium:

  • 1st step: Treat reversible causes (ex: antibiotics if infection is known or suspected, pain control)
  • 2nd step: Non-pharmacologic measures:
    • Frequent verbal patient orientation, reassurance, redirect, touch by a familiar (family) member or trained sitter at bedside, environmental modification (visual cues: clock on the wall, curtains open during daytime, date written on the board in the patient’s room)
  • If non-pharm strategies fail or the patient is a harm to self or others:
    • 3rd step: Trial of pharmacotherapy is indicated:
      • 1st: Typical antipsychotics (Haloperidol) or Atypical antipsychotics (Seroquel, Risperidone, or Olanzapine).
      • Check recent EKG to assess QTc as many antipsychotics can cause prolonged QTc.
        • Haldol (Haloperidol) [ADR: QT prolongation] – Do NOT give if QTc > 500!!! Look back at EKGs, get updated.
          • IM lactate (prompt-acting): 2-5mg IM X 1 dose (q4-8hrs PRN); may require q1hr in acute agitation. Or 1 MG = 1 TAB PO Q6HPRN AGITATION
          • ***Haloperidol (Haldol) lactate 2mg IM q6hrs PRN agitation***
          • ***Quetiapine (Seroquel) 50mg PO tid PRN agitation/psychosis***
            • Seroquel 12.5mg PO qHS (can go through NG tube).
            • Outpatient/long-term: Seroquel 100mg tablets: Take 1/2 tablet (50mg) for the first 2 days. Then take 1 whole (100mg) tablet for the next 2 days. Then take 2 tablets (200mg) every day after that
        • Agitation PO:
          • Ativan (lorazepam): 1mg PO q4-6hr PRN moderate agitation and 2mg PO q4-6hr PRN severe agitation
          • Haloperidol 5mg PO q4hr PRN agitation
          • Olanzapine 5mg sublingual tid
        • Agitation IM
          • Ziprasidone IM (Geodon): (NOT to exceed 40mg/24 hours)
            • Ziprasidone 10mg IM q6hr PRN mild/moderate agitation and/or geriatric status
            • Ziprasidone 20mg IM q8hr PRM severe agitation
        • Lorazepam (Ativan) IM 1mg IM q6hr PRN moderate agitation, 2mg IM q6hr PRN severe agitation
        • Aripiprazole IM (Abilify): 9.75mg IM q8hr PRN severe agitation
          • ****Does NOT cause QT prolongation!!!****
        • Haloperidol IM: 2-5mg IM q4-8hr (may require q1hr) moderate/severe agitation
    • 4th step (last resort): Physical restraints – can cause worsening agitation, can result in impaired mobility and pressure ulcers.
  • CAM: Confusion Assessment Method
    1. Used to diagnose delirium!

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