1. ·Antipsychotics are shown to treat symptoms of
delirium; there are few studies examining their
1,3
potential to prevent delirium.
· Haloperidol is most studied in elderly, terminally
ill, and ICU patients. More research is needed on
its safety & efficacy in medical-surgical patients.
· To date, there are no studies determining which
non-pharmacological therapies work best with
different drug therapies - nor which non-
pharmacological therapies work best in non-ICU
populations.
· Treat or remove reversible causes of delirium
before pharmacotherapeutic interventions. If IV
haloperidol is prescribed at > 8mg/day, research
dosage in Micromedex; contact prescribing
clinician with concerns.
· Treat side effects of haloperidol to decrease
patient distress.
· Assess, monitor, intervene to provide excellent
sleep hygiene. Adjust timing of medications &
nursing care; consider “healing environment” quiet
hours in hallway.
· Document specific patient behaviors & progress;
update prescribing clinician frequently.
· As nurse leaders, we remember that we are the
voice for patients who may not be able to speak
for themselves.
· Loading dose: .5 – 20 mg
· 2 mg for mild agitation; 5mg for moderate, 10 mg for severe
9,10
· Maintenance dose: 2.5 – 10mg q2h.
11
· > 8 mg/day is unlikely to resolve delirium and may increase its side effects
9
PO – take with food or full glass of water to minimize GI irritation.
9
IM – slowly using 2”, 21-g needle via Z-track.
Direct IV – May be administered undiluted for rapid control of symptoms;
9
5 mg/ml over 1 min.
Intermittent Infusion – May be diluted in 30 - 50 ml D5W, given over 30 min.
9
overall recommendations
patient differences
in response to
treatment
s/s of withdrawal
use cautiously
Patients who are elderly, in advanced
stages of a disease, or terminally ill
will experience more adverse effects
N/V, tardive dyskinesias, trembling,
10
dizziness.
In patients with underlying cardiac
disease, renal / hepatic impairment,
history or seizures, suicidality,
9,10
diabetes, drug abuse.
Precautions
future research
SCIENTIST
LEADER
Administration
pt characteristics
sleep deprivation
single, living at home
pain
male gender
age >65 yo
depression
alcohol w/d
chronic pathology
dementia
hypoxia (anemia, PE)
endocrinopathies
comorbidities
(COPD, stroke, seizure,
HF, hepatic/renal failure)
2,7,8
Risk factors for delirium
post-op
catheters, drains
UTIs, pneumonia
insufficient visitors, visible light,
clockslength of stay
physical restraintsfever; shock
hip fracture
medications
acute illness
more modifiable
lack of visitors
lack of visible light, clocks
physical restraints
environment
anything that ACh or DA
· anticholinergics
· tricyclic antidepressants (end in -tyline or -amine)
· benzodiazepines
· antibiotics
· CNS depressants
Acute onset, fluctuating:
inattention withdrawn affect
confusion hypervigilence
agitation sleep disturbances
paranoia hallucinations
6
Pharmacological interventions
Antipsychotics: block DA receptors & increase ACh
release, decreasing symptoms of delirium.
how is delirium treated?
Current or previous mental health diagnosis
2,8
is not a risk factor for delirium
Medications potentiating delirium
7,12
Pathophysiology of delirium
4,7
Symptoms
6,7
Nonpharmacological interventions
Frequent mobilization, normalized sleep-wake cycles,
ADLs, quiet / low-lit environment, adequate nutrition, re-
orientation, social interaction with clear instructions and
frequent eye contact. When possible, offer warm milk,
2
relaxing music with headphones & use of touch.
PRACTITIONER
limited or non-modifiable
Delirium is caused by excess DA and deficient ACh. DA is involved in movement
control, stimuli response, and cognition; ACh is involved in memory formation. As such,
excess DA causes the hallucinations, sleep disturbances, and agitation of delirium,
while lack of ACh causes the inattention.
Haloperidol is prescribed more often than antipsychotics because it causes less
6,11
respiratory depression and somnolence, and is more effective in treating agitation.
It causes more akethisias than atypical antipsychotics when administered PO, but IV
administration decreases these effects.
why haloperidol?
8
Other studies find no significant differences between haloperidol and atypical antipsychotics.
the controversy
SCIENTISTLEADER
PRACTITIONER
Professional
Transferor
of knowledge
Transferor
ofknowledge
Transferor
ofknowledge
Further Research
on Haloperidol
Recognition/
Management of Symptoms
& Side Effects
Documentation
Communication
Advocacy
… is not officially approved by the FDA to treat delirium.
… cannot reliably be generalized to non-ICU patients due
to insufficient randomized, placebo-controlled research in
4,9
non-ICU patients.
Haloperidol Atypical antipsychotics
(risperidone, olanzapine, seroquel)
… may be less likely to cause prolonged QT intervals and
EPS, and thus may be safer for patients who are already
at risk for complications due to these side effects (i.e.,
3,9,11
cardiac abnormalities, Parkinson's).
2,4,7
side effects of haloperidol treating the side effects
CNS: restlessness, , somnolence, , impaired body temp regulation
EENT: , dry eyes, blurred vision
Resp:
Cardiovascular:
tachycardia,
:
:
GU: , impotence
Skin: rashes, photosensitivity
confusion fever
dry mouth
RR depression
·hypotension, Torsades de Pointes
·extrapyramidal symptoms (EPS)
·akathisias
constipation
urinary retention
dystonia, mask-like face, rigidity, tremors,
drooling, shuffling gait, dysphagia.
need to be in constant motion, rocking, marching feet while sitting,
crossing / uncrossing legs; restless, fidget, pace
GI:
Life threatening, rare:
(fever, resp distress, tachy, seizures,
hypertension, hypotension, muscle stiffness, urinary incontinence, pallor,
5
fatigue).
• Seizures
• Agranulocytosis
• Neuroleptic Malignant Syndrome
Assess for confusion vs. s/s of delirium.
Ask pt if room needs to be cooler.
Maintain oral hygiene; offer mouthwash, swabs & gum as appropriate.
Raise HOB, C&DB, O2
Orthostatic hypotension – monitor pt standing up
+ 2+
Monitor K & Mg ; may require tele monitoring.
EPS – may need an order for benzodiazepines. Contact clinician with
concerns. Evaluate distress level of patient; reassure patient.
Fiber; stool softener
Offer frequent toileting; Pt may need brief
Assess skin & whether bed is too close to window
• Implement seizure protocol
• Assess for s/s infection & bleeding
• Monitor for & treat s/s of NMS
Special thanks to Megan Boyle, BSN, MSN, Pat O'Connor, RN, OCN, Dianne Wheeling, BSN, RN-BC and the staff on 14A!
Rheanna Hoffmann, School of NursingOregon Health and Science University,
Dispelling Myths:
Haloperidol as Treatment for Delirium