Delirium - Treatment

Treatment of delirium is carried out in two main directions. The priority is to identify and, if possible, eliminate the cause underlying the psychosis. The second direction is symptomatic therapy of behavioral disorders. Common behavioral disorders that respond to drug and psychotherapeutic treatment methods include sleep disorders, psychotic disorders, affective lability, psychomotor agitation, confusion, and anxiety.

Management of a patient with delirium

• Finding the cause
• Correction/elimination of the cause
• Cancellation of non-essential medicines
• Maximum/optimal correction of the underlying disease
• Creating a safe environment for the patient
• Providing adequate levels of stimulation
• Restoring the patient's orientation
• Explaining to patients and their caregivers the nature of the disease, its prognosis and treatment methods

Sleep disorders. Delirium may be combined with qualitative and quantitative changes in sleep. In somatic patients staying in hospital, sleep may be disturbed due to diagnostic procedures and other actions carried out in the ward. In this case, sleep can be normalized if unnecessary diagnostic procedures are abandoned and the level of stimulation is reduced to the optimal value for the patient. Some foods, medications, and exhaustion can increase insomnia or cause increased daytime sleepiness. It is necessary to analyze the medications taken by the patient, reducing the dose or canceling unnecessary drugs - this is the general principle of treating delirium.

Because day and night may be reversed in a patient with delirium, insufficient sleep should limit exposure to stimulating factors and avoid drugs with psychostimulant action. If the patient is already taking drugs with a sedative effect, they should be prescribed at night to improve the quality of sleep. In addition, low doses of trazadone, zolpidem, or low doses of benzodiazepines can be used to restore the sleep-wake cycle. If psychosis interrupts sleep, then neuroleptics can be used. Any drug with a sedative effect in the treatment of delirium should be used with caution. Patients with increased sleepiness are at increased risk of falls and aspiration, and they are often unable to cope with daily activities. Sometimes increased sleepiness is confused with anergy, a desire for isolation, depression, and despondency. If these symptoms are not associated with the action of sedatives, psychostimulants such as methylphenidate or dextroamphetamine can be useful. When using psychostimulants, careful monitoring of vital functions is necessary to promptly detect hyperactivity of the autonomic nervous system. When using these drugs, there is a risk of developing psychosis and increasing delirium.

Psychotic disorders. Hallucinations or delusions accompanying delirium may require the use of neuroleptics. High-potency drugs, such as haloperidol, are preferable to chlorpromazine or thioridazine, since they have a weaker anticholinergic effect. Atypical neuroleptics have recently come into use: clozapine, risperidone, olanzapine, quetiapine, etc. Although clozapine may cause epileptic seizures, drowsiness, and agranulocytosis, it may be the drug of choice for the treatment of psychosis in patients with severe parkinsonism. Risperidone is less likely to cause extrapyramidal side effects than typical neuroleptics. However, the effectiveness of this drug in delirium has not yet been sufficiently studied, and it is also available only in tablet form for oral administration. Clinical experience shows that parkinsonism may develop within a few weeks or months of starting treatment with risperidone. Because olanzapine is less likely to cause parkinsonism, it can also be used to treat delirious psychosis. Side effects of olanzapine include drowsiness and hypotension. The efficacy of another atypical antipsychotic, quetiapine, in delirium has not been adequately studied. Its side effects include drowsiness, dizziness, and orthostatic hypotension. Once delirium has resolved, antipsychotics should be discontinued to reduce the likelihood of side effects.

Affective lability. Although affective lability is a common manifestation of delirium, it usually does not require pharmacological correction, such as the use of mood stabilizers or antidepressants, unless the patient is depressed or manic. To reduce affective lability, it is necessary to take care of the patient's safety, explain the nature of the disease and the available treatment options, explain where he is, and assure him that he is not "crazy." Explaining the nature of the disease and the relationship between behavioral disorders and delirium can be useful not only for the patient, but also for his relatives or caregivers.

Psychomotor agitation. In cases where delirium occurs with pronounced agitation, patients usually attract more attention from the staff and receive more intensive therapy than patients with "silent" delirium, who pull the sheets over themselves, do not scream or rush about. Although physical restraint can be used to protect the patient from harm, it should be used as a last resort - when other, less restrictive measures are ineffective. Restraint often only increases agitation and, if used incorrectly, can lead to injury and even death. Physical agitation can interfere with the diagnostic measures necessary to establish the cause of delirium. In order to calm the patient in this case, you can involve his relatives, who can have a favorable effect on him, support him, convince him of the need for the procedure. In this regard, it is advisable to explain to relatives or friends, persons caring for him what are the causes of delirium, how it progresses, what is the purpose of this or that study, how the treatment is carried out.

Low doses of high-potency neuroleptics can be used to reduce psychomotor agitation. Haloperidol can be administered orally, intramuscularly, or intravenously. Intravenous haloperidol should be administered with caution because it can provoke cardiac arrhythmia, including torsades de pointes. The duration of the QTc interval has proven to be an important prognostic indicator that can predict the likelihood of developing arrhythmia with intravenous butyrophenones. A combination of a neuroleptic and a benzodiazepine is often used to relieve psychomotor agitation because their sedative effects can be additive. If a loved one is constantly with the patient, the need for physical restraint or drug therapy is often significantly reduced.

Confusion. Fluctuations in attention and frequent disorientation are the main signs of delirium. Behavioral measures can be used to reduce confusion, in particular providing orientation cues. For example, a large clock can help reduce confusion, allowing the patient to easily determine the time, calendar, familiar objects, constant lighting, and the location of someone close. Specific pharmacotherapy for confusion has not been developed. General principles of treatment include identifying the cause of delirium, ensuring the patient's safety, reducing the dose, or discontinuing medications that are not essential.

Anxiety. Severe anxiety, panic, and symptoms of post-traumatic stress disorder may occur at various stages of delirium. Patients who do not understand what is happening around them are often disoriented, have psychotic disorders, and are sleep-deprived for a long time. After delirium has ceased, short-term supportive psychotherapy can help to de-actualize frightening and disturbing memories of delirium. Certain difficulties may be associated with the mosaic nature of memories of what happened during delirium. Benzodiazepines can be used to reduce anxiety, and neuroleptics can be used if psychotic disorders arise against the background of anxiety.

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