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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 6: Anxiety, Delirium, Depression
    Assessment and Management of Delirium

    Assessment of Delirium
    Management of Delirium

    Assessment of Delirium in Advanced Illness

    • The diagnosis needs to be distinguished from:
      • anxiety,
      • depression and
      • dementia (which is slowly progressive, usually irreversible, and commonly associated with unaltered consciousness until very late in its course)
    • A tool such as the Folstein mini-mental status exam can be used for more definitive assessments

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    Management of Delirium in Advanced Illness

    General Considerations in the Treatment of Delirium

    • Management of delirium begins by first evaluating the benefits vs burdens of seeking and treating reversible causes
      • For some patients, it may be most efficacious to try to treat the delirium rather than search for the underlying cause
    • In all cases, it makes sense to review the medication list and try to relate changes in medication to the onset of the symptoms
      • If medications are felt to be responsible, consider removing those that are nonessential
    • General treatment measures are frequently beneficial
      • If the patient must be in the hospital, try to ensure that family and caregivers are present as much as they can be

      • Reduce excessive stimulation, and regularly orient and assure the patient of his or her safety regularly

      • Familiar surroundings are more likely to be calming. If possible, discharge the patient home with the necessary supports in place, e.g., home hospice

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    Neuroleptics

    • If medications are needed, neuroleptics may be helpful
    • Monitor for extrapyramidal adverse effects, e.g., dystonia or akathisia
      haloperidol
      • 0.5–1 mg po, iv, sc q 1h prn, titrate until settled, then q 12 to q 6h to maintain

      • Total daily doses of 1–20 mg or more may be needed

      • Less sedating than chlorpromazine
      chlorpromazine
      • 10–25 mg po/iv q 4–6h for sedating neuroleptic

      • Low doses are ideal for nighttime sedation, especially with day-night reversal, and/or in the elderly

      • Delirium may worsen in some patients because of chlorpromazine’s anticholinergic effect

      • It also lowers the seizure threshold

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    Atypical Neuroleptics

    • Cause less dystonia and akathisia than typical neuroleptics
    • Risperidone may be better in demented or agitated delirium
      • risperidone 0.5–1 mg q 12 and titrate
    • Sedating atypical neuroleptics (e.g., olanzepine, quetiapine) are alternatives to chlorpromazine, though they have been less extensively used or studied in this population
      • olanzepine 2.5–7.5 mg po q 12h
      • quetiapine 75–100 mg po q 12h

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    Management of Terminal Delirium

    • Management is focused on:
      • Symptomatic control
      • Relief of the distress of both patient and family

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    Evaluating Treatment

    • Patients on medication for delirium should be monitored carefully and regular meetings arranged to discuss their progress
    • If there is a negligible or only partial response:
      • Reevaluate the diagnosis
      • Consider adjusting the dosage
      • Try a different medication
      • Inquire of family members and caregivers about adherence to medication
    • If delirium persists, seek advice from, or refer to, a specialist
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