Agitated Delirium - Management
Safety: #1 priority is patient and staff safety. LISTEN to nursing concerns.
• Very low threshold to page security, particularly if patient has a history of violence
• Can always page psychiatry (page APS resident after 6PM on weekdays/5PM on weekends)
• Offer oral medications early. Consider lorazepam 1st line if strong suspicion for stimulant intoxication or catatonia
• If patient requires restraints, ensure appropriate sedation as agitated patients are at risk of rhabdo/MSK injury
• 2nd generation antipsychotics carry a black-box warning for increased all-cause mortality in pts with dementia (who commonly present with superimposed delirium) – goal is lowest effective dose for shortest time possible
Treat underlying cause:
• Carefully review pts’ medications and assess risk/benefit of continuing anticholinergics & benzodiazepines. If opiates are required, consider preferentially using PO oxycodone or hydromorphone if IV needed
• Use behavioral strategies (including frequent re-orientation& light/physical activity (OOB/PT) cues) as first-line
• If medication is required for adults with QTc<550ms, can trial oral quetiapine (initial doses 12.5-25mg q6 hrs)
• If requires IV, trial IV haloperidol (initial dose 2.5-5mg, 1-2mg in elderly/frail). May be effective and is less associated
with dystonia than IM or PO dosing. Prefer early psych consultation for pts requiring higher/more frequent doses.
• Monitor QTc, replete mag ≥2.0 and K ≥4.0 while using antipsychotics.
• AVOID antipsychotics in patients with Parkinsonian syndromes, catatonia, NMS
IM medications: Use only as a last resort in case of emergencies. Consult psychiatry for pts requiring IMs.
• IM haloperidol (5mg) should be co-administered with either IM diphenhydramine (25-50mg) or IM benztropine (0.5-1mg) to reduce risk of dystonia although these medications may temporarily worsen delirium.
• IM olanzapine or thorazine may be given alone but should be used cautiously in elderly pts given risk of orthostasis
• IM olanzapine cannot be administered with IM benzos/barbiturates due to risk of cardiorespiratory depression
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