Delirium: Treatment

Treatment of delirium is carried out in two main directions. Priority is the identification and, if possible, the elimination of the underlying cause of psychosis. The second direction is symptomatic therapy of behavioral disorders. Frequent behavioral disorders that react to medication and psychotherapeutic treatments include sleep disorders, psychotic disorders, affective lability, psychomotor agitation, confusion and anxiety.

Management of a patient with delirium

• Revealing the cause
• Correction / elimination of the cause
• Removal of non-essential medicines
• Maximum / optimal correction of underlying disease
• Creating a safe environment for the patient
• Ensuring an adequate level of stimulation
• Restoring patient orientation
• Explaining to patients and caregivers, the nature of the disease, its prognosis and methods of treatment

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

Since a patient with delirium may change places day and night, in case of insufficient sleep, it is necessary to limit the effect of stimulating factors and exclude drugs with psychostimulating action. If the patient is already taking medications with a sedative effect, they should be prescribed at night - in order to improve the quality of sleep. In addition, small doses of trazadone, zolpidem, or small doses of benzodiazepines can be used to restore the cycle of sleep and wakefulness. If psychosis interrupts sleep, then you can use neuroleptics. Any drug with a sedative effect in the treatment of delirium should be used with caution. In patients with increased drowsiness, the risk of falls and aspiration is increased, they are often unable to cope with daily activities. Sometimes the increased drowsiness is confused with anergy, the desire for isolation, depression and depression. If these symptoms are not associated with the action of sedatives, then psychostimulants, for example, methylphenidate or dextraamphetamine, may be useful. When using psychostimulants, careful monitoring of the vital functions for timely detection of hyperactivity in the autonomic nervous system is necessary. When using these drugs, there is a risk of developing psychosis and increasing delirium.

Psychotic disorders. Hallucinations or delusions accompanying delirium may require the appointment of neuroleptics. High-potential drugs, for example, haloperidol, are preferable to chlorpromazine or thioridazine, since they have a weaker anticholinergic effect. Relatively recently, atypical antipsychotics have been used: clozapine, risperidone, olanzapine, quetiapine, etc. Although clozapine may develop epileptic seizures, drowsiness and agranulocytosis, it may be the drug of choice in the treatment of psychosis in patients with severe Parkinsonism. Risperidone rarely causes extrapyramidal side effects than typical neuroleptics. However, the effectiveness of this drug in delirium has not yet been adequately studied, in addition, it is only available in the form of oral tablets. Clinical experience shows that in a few weeks or months after the beginning of treatment with risperidone Parkinsonism may develop. Since olanzapine less often causes Parkinsonism, it can also be used to treat delirious psychosis. Side effects of olanzapine include drowsiness and hypotension. The efficacy of another atypical neuroleptic quetiapine in delirium has not been adequately studied. Its side effects include drowsiness, dizziness and orthostatic hypotension. After the termination of delirium, antipsychotics should be discontinued to reduce the likelihood of side effects.

Affective lability. Although affective lability is a frequent manifestation of delirium, it usually does not require pharmacological correction, for example, the appointment of normotimic drugs or antidepressants if the patient does not have depression or mania. To reduce affective lability, one should take care of the patient's safety, explain the nature of the disease and the available treatment options, explain where he is, to assure that he is not "crazy". The explanation of the nature of the disease, the connection of behavioral disorders with delirium is useful not only for the patient, but also for his relatives or caregivers.

Psychomotor agitation. In cases where delirium occurs with marked excitement, patients usually attract more attention of the staff and receive more intensive therapy than patients with a "quiet" delirium who pull on themselves sheets, do not shout and do not rush. Although physical fixation can be used to protect a patient from damage, it should be resorted to in the last place - if other, less restrictive measures are ineffective. Fixation often only increases excitement and, if misused, can lead to damage and even death. Physical excitement can interfere with the diagnostic activities necessary to establish the cause of delirium. To calm the patient in this case it is possible to involve his relatives who are able to have a favorable effect on him, support, convince him of the need for a procedure. In this regard, relatives or friends, caring for him, it is advisable to explain what the causes of delirium, how it proceeds, what the purpose of this or that research, how treatment is conducted.

To reduce the treatment of psychomotor agitation, small doses of high-potential neuroleptics can be used. Haloperidol can be administered orally, intramuscularly or intravenously. Intravenous haloperidol should be administered with caution, as it can provoke a disturbance of the heart rhythm, including pirouette ventricular tachyarrhythmia. The duration of the QTc interval proved to be an important prognostic sign that could predict the probability of arrhythmia with intravenous administration of butyrophenones. To stop psychomotor agitation often resort to a combination of neuroleptic and benzodiazepine, since their sedative effect can be summarized. If someone is always with the patient, then the need for physical fixation or drug therapy is often significantly reduced.

Confusion of consciousness. Fluctuations of attention and frequent disorientation are the main signs of delirium. To reduce confusion, behavioral measures can be used, in particular, to provide orienting reference signals. For example, a large clock can help to reduce confusion, with the help of which the patient can easily determine the time, calendar, familiar objects, constant illumination, and the whereabouts of someone close. Specific pharmacotherapy of confusion is not developed. The general principles of treatment are to find out the cause of delirium, care for the safety of the patient, reduce the dose or cancel drugs that are not required.

Anxiety. Severe anxiety, panic, symptoms of post-traumatic stress disorder can occur at various stages of delirium. Patients who do not understand what is happening around, are often disoriented, have psychotic disorders, have been deprived of sleep for a long time. After cessation of delirium, short-term supportive psychotherapy can help in deactuating intimidating and disturbing memories of delirium. Certain difficulties in this case may be related to the mosaic of memories of what happened during the delirium. To reduce anxiety, you can use benzodiazepines, and in the event that psychotic disorders occur against the background of anxiety, neuroleptics.

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