Delirium
Description General measures Medicine treatment ICD-10 code: F05.0-1/F05.8-9/R45.1/R45.4-6 DESCRIPTION Delirium is a disturbance in attention, awareness (reduced orientation to the environment), and cognition (e.g. memory deficit, language, visuospatial ability, or perception). It is acute, developing within hours to days, and fluctuates during the day, worsening in the evenings. It may be hypera
ICD-10 code: F05.0-1/F05.8-9/R45.1/R45.4-6
DESCRIPTION
Delirium is a disturbance in attention, awareness (reduced orientation to the environment), and cognition (e.g. memory deficit, language, visuospatial ability, or perception). It is acute, developing within hours to days, and fluctuates during the day, worsening in the evenings. It may be hyperactive, with increased mood lability, agitation, and/or uncooperative behavior, or hypoactive, with poor responsiveness and stupor.
Delirium should not be mistaken for a psychiatric disorder. It is a physiological consequence of another medical condition, substance intoxication or withdrawal (including prescription or over the counter medications and recreational substances), exposure to a toxin, or multiple etiologies. Risk factors include
- > 65 years of age
- dementia
- history of previous delirium or of falls
- history of stroke, epilepsy, or other neurological disorders
- HIV infection
- multiple comorbidities
- medicines such as anticholinergics, hypnotics, and opioids
- polypharmacy
- psychoactive substance use
- severe illness
GENERAL MEASURES
- Investigations need to be done to exclude or diagnose an underlying medical problem, the treatment of which is the primary management.
Checklist for diagnosis:
D Drugs (Intoxication and withdrawal. Consider Wernicke’s encephalopathy).
I Infections, e.g. sepsis, pneumonia, urinary tract infections, peritonitis, meningitis.
M Metabolic, e.g. hypoglycaemia, electrolyte abnormalities (e.g. hyponatraemia); organ failure (e.g. liver failure, renal dysfunction), CO2 narcosis.
T Trauma, e.g. chronic subdural haematoma.
O Oxygen deficit (including hypoxia, carbon monoxide poisoning).
P Psychiatric or physical conditions, e.g. severe stressor pain.
- Assess for and address dehydration, constipation, hypoxia, infections, pain, and discomfort.
- Avoid abrupt substance withdrawal (see Adult Hospital STGs and EML: Mental Health Conditions, Substance Misuse).
- Review all medicines that the person has been taking – optimise doses; gradually wean and stop any unnecessary medication, including sedatives and analgesics.
Nursing interventions:
- Nurse in calm, predictable environment, avoid changes of staff or rooms.
- Maintain circadian rhythm: in the day mobilise, provide sensory stimulation/ spectacles/ hearing aids; at night avoid noise, light and procedures.
- Ensure effective communication: introduce self with each patient contact, be aware of patient’s non-verbal cues, listen attentively, reassure frequently.
- Re-orientate verbally, with a clock, and signage.
CAUTION – Physical restraint
- Worsens the outcomes of delirious patients: this is a last resort when all else has failed and is a short-term measure until chemical restraint and other measures have been achieved.
- Manual restraint: respectful, controlled, applied by personnel of the same sex as the patient.
- Mechanical restraint: only if absolutely necessary to protect the patient and others for as short a time as possible. Document the type, sites and duration of any restraints used. 15-minute monitoring of vital signs, the mental state, restraint sites, and reasons for use.
MEDICINE TREATMENT
- Treat the underlying medical or surgical condition.
- Keep antipsychotic or benzodiazepine use to a minimum.
- Use small doses regularly rather than large doses less frequently.
- Adjust doses according to clinical circumstances, e.g., lower doses in the elderly, debilitated, or where HIV infection or HIV-related dementia is known or suspected.
Acute management
For management of severe aggression and disruptive behaviour:
see: Aggressive disruptive behaviour in adults.
For agitated and acutely disturbed patient:
- Haloperidol, oral, 0.75–1.5 mg twice daily
- May be repeated 4 hourly if needed to a maximum dose of 10mg in 24 hours.
- May be continued short-term (usually 7 days or less) at lowest dose at which behaviour is contained.
OR
If unable to swallow or oral medication declined:
- Haloperidol, IM, 0.5–1mg
- May be repeated after 30–60 minutes if needed and then 4 hourly, to a maximum dose of 10mg in 24 hours.
- Monitor vital signs and beware of acute dystonia, other extra-pyramidal side effects, and neuroleptic malignant syndrome.
OR
If haloperidol, IM is not available:
- Olanzapine, oral dispersible tablet or IM, 2.5–5 mg.
- This can be repeated in 30–60 minutes, if required and then 6 hourly, to a maximum dose of 20 mg within 24 hours.
- Monitor vital signs and beware of oversedation, neuroleptic malignant syndrome, and acute dystonia.
OR
For substance withdrawal, Parkinson’s disease, or intolerability to haloperidol or olanzapine:
- Benzodiazepine, repeat as necessary, to achieve containment, e.g.:
- Lorazepam, IM, 0.25–1 mg, 2 to 4 hourly, maximum dose 3 mg in 24 hours
OR
- Clonazepam, IM, 0.5–2 mg.
OR
- Diazepam, IV, 5–10 mg.
- Switch to oral route once containment is achieved.
- In the elderly, a starting dose of 2 mg is recommended.
CAUTION - Benzodiazepines
- Can cause respiratory depression, especially diazepam IV.
- Can aggravate delirium.
- In the frail and elderly patient or where respiratory depression is a concern, reduce the dose by half.
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- The safest route of administration is oral followed by IM; IV route has the highest risk of respiratory depression and arrest.
- Monitor vital signs closely during and after administration.
- Allow at least 15–30 minutes for the medication to take effect. Repeated IM doses of benzodiazepines may result in toxicity owing to accumulation.
If alcohol withdrawal/ Wernicke’s encephalopathy suspected:
- Thiamine, IM, 200 mg immediately.
Click here for the Supporting NEMLC report and reviews_(2020-4 review cycle).
Standard Treatment Guidelines And Essential Medicines List For South Africa, Adult Hospital level, 2020-4_Version 1_June 2024
Chapter 20: Emergencies and Injuries