Delirium Management

1. DELIRIUM
FOCUS ON MEDICAL TREATMENT
Ade Wijaya, MD
August 2017

2. OUTLINE
• DEFINITION
• CLASSIFICATION
• TREATMENT
- MEDICAL TREATMENTS
*ANTIPSYCHOTICS
*OTHER MEDICATIONS
• SUMMARY

3. DSM-IV CRITERIA FOR DELIRIUM
• DISTURBANCE OF CONSCIOUSNESS (I.E., REDUCED CLARITY OF AWARENESS OF
THE ENVIRONMENT) WITH REDUCED ABILITY TO FOCUS, SUSTAIN, OR SHIFT
ATTENTION.
• A CHANGE IN COGNITION (SUCH AS MEMORY DEFICIT, DISORIENTATION,
LANGUAGE DISTURBANCE) OR THE DEVELOPMENT OF A PERCEPTUAL
DISTURBANCE THAT IS NOT BETTER ACCOUNTED FOR BY A PREEXISTING,
ESTABLISHED, OR EVOLVING DEMENTIA.
• THE DISTURBANCE DEVELOPS OVER A SHORT PERIOD OF TIME (USUALLY HOURS
TO DAYS) AND TENDS TO FLUCTUATE DURING THE COURSE OF THE DAY.American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM-IV). Washington, DC, APA, 1994 [F]

4. CLASSIFICATION
• 1. DELIRIUM DUE TO A GENERAL MEDICAL CONDITION.
• 2. SUBSTANCE-INDUCED DELIRIUM.
• 3. DELIRIUM DUE TO MULTIPLE ETIOLOGIES.
• 4. DELIRIUM NOT OTHERWISE SPECIFIED.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM-IV). Washington, DC, APA, 1994 [F]

5. TREATMENT
• TREATING THE UNDERLYING CONDITIONS
• PSYCHIATRIC MANAGEMENT
• ENVIRONMENTAL AND SUPPORTIVE INTERVENTIONS
• SOMATIC INTERVENTIONS / MEDICAL TREATMENTS
Trzepacz, P., Breitbart, W., Franklin, J., Levenson, J., Martini, D. R., & Wang, P. (2010). Treatment of Patients With Delirium.

6. MEDICAL TREATMENTS
• ANTIPSYCHOTICS
• BENZODIAZEPINES
• CHOLINERGICS
• VITAMINS
• MORPHINES AND PARALYTIC AGENTS
Trzepacz, P., Breitbart, W., Franklin, J., Levenson, J., Martini, D. R., & Wang, P. (2010). Treatment of Patients With Delirium.

7. ANTIPSYCHOTICS
• DRUG OF CHOICE
• HALOPERIDOL  SAFEST AND EFFECTIVE
• SIDE EFFECTS: NEUROLOGICAL, PROLONGED QT INTERVAL, LOWERING SEIZURE THRESHOLD, INHIBIT
LEUKOPOESIS, GALACTHORREA, ELEVATION OF LIVER ENZYMES
• IV  LESS EXTRAPYRAMIDAL EFFECTS
• STARTING DOSE: 2-4 MG EACH 2-4 HOURS, ELDERLY: 0,25-0,5 MG EACH 2-4 HOURS
SEVERE CASES: UP TO 50 MG EACH 2-4 HOURS, MAXIMUM 500 MG DAILY
• IN PATIENTS WHO NEEDS MORE THAN 8 X 10 MG PER DAY OR 10 MG / HOUR FOR 5 CONSECUTIVE
HOURS  CONTINUOUS DRIP (BOLUS 10 MG CONTINUED WITH 5-10 MG / HOUR)
• MONITOR ECG AND ELECTROLYTES
Trzepacz, P., Breitbart, W., Franklin, J., Levenson, J., Martini, D. R., & Wang, P. (2010). Treatment of Patients With Delirium.

8. OTHER MEDICATIONS
• BENZODIAZEPINES: LORAZEPAM AS ADD ON DRUG ALONG WITH HALOPERIDOL
• CHOLINERGICS: PHYSOSTIGMINE
• VITAMINS:
- NICOTINAMIDE 500 MG /DAY IN DIALYSIS PATIENTS
- VITAMIN B IN ALCOHOLIC AND MALNOURISHED PATIENTS
• MORPHINES IN PATIENTS WITH PAIN
• PARALYTIC AGENTS AND MECHANICAL VENTILATION
Trzepacz, P., Breitbart, W., Franklin, J., Levenson, J., Martini, D. R., & Wang, P. (2010). Treatment of Patients With Delirium.

9. SUMMARY
• DELIRIUM IS A DISTURBANCE OF CONSCIOUSNESS AND CHANGE IN COGNITION
WHICH IS FLUCTUATIVE OVER SHORT PERIOD OF TIME
• COULD BE CAUSED BY MEDICAL CONDITIONS, SUBSTANCE WITHDRAWAL, MULTIPLE
ETIOLOGIES, OR NON-SPECIFIED DELIRIUM
• MANAGEMENT SHOULD INCLUDE TREATING UNDERLYING CONDITIONS, PSYCHIATRIC
MANAGEMENT, SUPPORTIVE AND SOMATIC INTERVENTIONS
• HALOPERIDOL IS THE DRUG OF CHOICE IN TREATING DELIRIUM
• OTHER TREATMENT CHOICES INCLUDING LORAZEPAM, PHYSOSTIGMINE,
NICOTINAMIDE, VITAMIN B, MORPHINE, AND PARALYTIC AGENTS