neurologic disorders
Delirium
Treatment of Delirium
Correction of the cause and removal of aggravating factors Supportive care Management of agitation Correcting the cause (eg, treating infection, giving fluids and electrolytes for dehydration) and removing aggravating factors (eg, stopping medications or drugs) may result in resolution of delirium. Nutritional deficiencies (eg, of thiamin or vitamin B12) should be corrected, and good nutrition and hydration should be provided. The environment should be stable, quiet, and well-lit and include visual cues to orient the patient (eg, calendar, clocks, family photographs). Frequent reorientation and reassurance by hospital staff or family members may also help. Sensory deficits should be minimized (eg, by replacing hearing-aid batteries, by encouraging patients who need eyeglasses or hearing aids to use them). Approach to treatment should be interdisciplinary (with a physician, physical and occupational therapists, nurses, and social workers); it should involve strategies to enhance mobility and range of motion, treat pain and discomfort, prevent skin breakdown, ameliorate incontinence, and minimize risk of aspiration. Agitationmay threaten the well-being of the patient, a caregiver, or a staff member. Simplifying medication regimens and avoiding use of IV lines, bladder catheters, and physical restraints (particularly in the long-term care setting) as much as possible can help prevent exacerbation of agitation and reduce risk of injury. However, in certain circumstances, physical restraints may be needed to prevent patients from harming themselves or others. Restraints should be applied by a staff member trained in their use; they should be released at least every 2 hours to prevent injury and discontinued as soon as possible. Use of hospital-employed assistants (sitters) as constant observers may help avoid the need for restraints. Explaining the nature of delirium to family members can help them cope. They should be told that delirium is usually reversible but that cognitive deficits often take weeks or months to abate after resolution of the acute illness. Medications, typically low-dosehaloperidol(0.5 to 1.0 mg orally, IV, or IM once, then repeated every 1 to 2 hours as needed), may lessen agitation or psychotic symptoms; occasionally, much higher doses are necessary. However, medications do not correct the underlying problem and may prolong or exacerbate delirium. Second-generation (atypical) antipsychotics (eg,risperidone0.5 to 3 mg orally every 12 hours,olanzapine2.5 to 15 mg orally once a day,quetiapine25 to 200 mg orally every 12 hours) may be preferred because they have fewer extrapyramidal adverse effects; however, long-term use may cause weight gain and hyperlipidemia and increase the risk of type 2 diabetes. In older patients with dementia-related psychosis, these medications increase risk of stroke and death. These medications are typically given orally and not parenterally. Benzodiazepines (eg,lorazepam0.5 to 1.0 mg orally or IV once, then repeated every 1 to 2 hours as needed) are the medications of choice for delirium caused by withdrawal from alcohol or benzodiazepines. Their onset of action is more rapid (5 minutes after parenteral administration) than antipsychotics. Benzodiazepines should be avoided if delirium results from other conditions because these medications worsen confusion and sedation. 