Delirium - include acute onset, waxing and waning symptoms, inattention (eg. unable to recite days of the week backwards), change in cognition (eg new memory deficit, disorientation, perceptual disturbance, or disorganized thinking) or altered level of awareness (reduced orientation to environment such as RASS other than 0)

Delirium: can be - Hyperactive (agitation and restlessness)

                                   Hypoactive (somnolence, decreased mental status)

                                   Mixed

Causes:  hypoxia, hypoglycemia, infection, stroke, electrolyte abnormalities, medications, environmental factors, STEMI, other      

Evaluate medications: High risk medications: sedatives, steroids, antihistamines, anti-cholinergics, TCAs, muscle relaxants, or opioids.

Exam: VS, glucose, labs, trauma assessment, neurological exam and appropriate systems

Evaluate

• Order: CBC, CMP, glucose level, EKG -->  STAT
• Other labs: specific drugs level, TSH, ETOH and drugs level

Prevent

• treat underlying condition: infection, nausea, constipation
• avoid high risk medications (see above)
• provide hydration, food, environment, visual and hearing assist, day/night light, stop night disruption including unnecessary VS
• Avoid tethers unless necessary, including: Foley catheters, continuous IV infusions, BP cuffs, monitors

Treat

• Use verbal de-escalation principles (respect person and space, do not provocative, establish verbal contact, use simple language, listen, feed) Avoid meds until nonpharm remedies are exhausted.
• Haloperidol 1-2.5 mg --> caution in patients with Parkinson (PO, IM)
• Chlorpromazine 25-50 mg --> better in controlling symptoms
• Start oral medications:  Risperidone ≤1mg  or Olanzapine 2.5-5mg –-> GDR ASAP
• Lorazepam 0.5-1 mg --> agitation with  Bi-polar and Dementia
• Avoid the use of benzodiazepines if possible unless withdrawal. 
• Do not use medications such as diphenhydramine for agitation in elderly patients

Quick Reference: Standard Adult Dosing

(Note: Geriatric dose should be decreased)

* IM chlorpromazine is not recommended as an option for the management of acute agitation due to significant risk of QTc prolongation and hypotension in doses required for acute agitation, slow onset of effect, and local irritation at the injection site (NICE guidelines)

**Reconstitution required before administration

Comparison of Oral Agents for Acute Agitation

* Not studied as a treatment for acute agitation and aggression

** The absorption of oral ziprasidone is significantly decreased in the absence of a meal (250-500 calories)

*** When given in combination with IM lorazepam 

• After treatment with IM agents: monitor vitals and clinical status at regular intervals. 
• Allow adequate time for clinical response between doses.
• Use lower starting and maximum doses 

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Created by NODAR JANAS, M.D.