Delirium
Description General Measures Medicine Treatment Referral ICD-10 code: F05.0-1/F05.8-9/F44.8/R45.1/R45.4-6 DESCRIPTION Delirium is a medical emergency. Delirium is a disturbance in attention, awareness (reduced orientation to the environment), and cognition (e.g. deficits in memory, language, visuospatial ability, or perception). It is acute, developing within hours to days, and fluctuates during
ICD-10 code: F05.0-1/F05.8-9/F44.8/R45.1/R45.4-6
DESCRIPTION
Delirium is a medical emergency.
Delirium is a disturbance in attention, awareness (reduced orientation to the environment), and cognition (e.g. deficits in memory, 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 behaviour, or hypoactive, with poor responsiveness and stupor.
Delirium should not be mistaken for psychiatric disorders like schizophrenia or a manic phase of a bipolar 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 aetiologies.
There are many possible causes including extracranial causes. Organic or physical illness should also be considered as possible causes.
The elderly are particularly prone to delirium caused by medication, infections, electrolyte and other metabolic disturbances.
Main clinical features are:
- acute onset (usually hours to days)
- confusion
- impaired awareness
- disorientation
- a fluctuating course and disturbances of the sleep-wake cycle
Other symptoms may also be present:
- restlessness and agitation
- hallucinations
- autonomic symptoms such as sweating, tachycardia and flushing
- hypo-activity, with reduced responsiveness to the environment
- aggressiveness
- violent behaviour alone occurs in exceptional cases only
Risk factors for delirium include:
- > 65 years of age
- dementia
- history of stroke, neurological disorder, falls, previous delirium
- medicines such as anticholinergics and hypnotics
- HIV infection
- multiple comorbidities
- polypharmacy
- severe illness
- psychoactive substance intoxication and withdrawal
GENERAL MEASURES
- Perform investigations to exclude or diagnose an underlying medical problem, the treatment of which is the primary management (e.g. hypoglycaemia, hypoxia, pain etc).
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 stress or pain.
- Nurse in a calm, predictable and safe environment, avoid changes of staff or rooms/ wards.
- 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
- Assess for and address dehydration, constipation, hypoxia, infections, pain, and discomfort.
- Avoid abrupt substance withdrawal (see: Substance use disorders).
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
- Manage the underlying medical or surgical condition.
- The aim is to contain the person while awaiting transfer to hospital and to enable initial care of the underlying 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
Acute management
For severe aggression and disruptive behaviour, see: Aggressive, disruptive behaviour in adults or Aggressive, disruptive behaviour in children and adolescents.
If the delirium is caused by seizures or substance withdrawal, or if communication is difficult
- Midazolam, IM, 7.5–15 mg immediately.
- Repeat after 30–60 minutes if needed.
OR
- Diazepam, slow IV, 10 mg no faster than 5 mg/minute for immediate sedative or hypnotic action.
- If no response, give a 2nd dose after 30 to 60 minutes.
Switch to oral administration, once containment is achieved.
- Secure airway.
- Exclude hypoglycaemia.
- Monitor for respiratory depression.
CAUTION - Benzodiazepines
- Benzodiazepines, especially diazepam IV, can cause respiratory depression.
- Monitor vital signs closely during and after administration. In the frail and elderly patient or where respiratory depression is a concern, reduce the dose by half.
- The safest route of administration is oral followed by IM with the IV route having the highest risk of respiratory depression and arrest. Use the safest route wherever possible.
- In patients with respiratory insufficiency: use oral haloperidol or olanzapine orodispersible tablets, IM, or oral instead of IM or IV benzodiazepines.
- Do NOT use IM olanzapine with IM/IV benzodiazepines.
- In the short-term, benzodiazepines can aggravate delirium.
- 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 the most likely cause of delirium is a medical disorder and if very restless or agitated:
- Haloperidol, oral, 0.75–1.5 mg, repeated in 30–60 minutes, if required
OR
If unable to swallow or oral medication declined:
- Haloperidol, IM, 0.5–1mg.
OR
If haloperidol, IM is not available:
- Olanzapine, oral dispersible tablet or IM, 2.5–5 mg.
- Use lowest dose with caution in the elderly
- May be repeated in 30–60 minutes, if required
- Monitor vital signs and beware of oversedation, neuroleptic malignant syndrome, and acute dystonia.
If alcohol withdrawal/ Wernicke’s encephalopathy suspected:
- Thiamine, IM, 200 mg immediately.
See: Alcohol withdrawal (uncomplicated).
CAUTION
Thiamine should preferably be administered prior to intravenous glucose to prevent permanent neurological damage.
Do not delay the dextrose administration in a hypoglycaemic patient.
REFERRAL
Urgent
All cases.
Click here for the Olanzapine Delirium PHC/Adults Review Updated 28 Mar 2024.
Click here for the NEMLC Recommendations for medicine amendments (2020-4 review cycle).
Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-4_Version 1.1_October 2024
Chapter 21: Emergencies and Injuries