Delirium

Vignette:

A 60 year old man with a history of esophageal cancer was in his usual state of health until a stent in his esophagus became dislodged and fell into his stomach. Following surgery to remove the stent, the patient had complications and ended up in the ICU for 6 weeks, when he suddenly developed delirium. He began climbing out of bed, pulling out his NG tube, and was put in restraints. What is the best way to treat delirium in an acute hospital setting?

Discussion:

Delirium is distressing for patients, families, and heath care staff. This can be a particularly difficult situation for the loved ones who have watched this patient deteriorate. A discussion of goals of care between the various physicians involved and the family members of the patient is recommended first. Consider a palliative care consult, and potentially a psychiatry consult as well, to help sort out the many issues. Delirium is a medical condition and requires skill in diagnosis and treatment. If the delirium is assessed to be potentially reversible, and that is consistent with goals of care, treat the underlying cause while administering psychotropic drugs to manage the agitation. For this patient, haloperidol 2 mg subcutaneously to start and 1-2 mg subcutaneously, doubled every 30 minutes until settled is recommended, followed by equivalent dosing on the half-life. Equivalent doses of chlorpromazine can be considered as an alternative.

If delirium is not reversible or reversing is not consistent with goals of care, then controlling agitation with benzodiazepines should be considered. 1-2 mg of lorazepam buccally to start, doubling every hour until settled, followed by equivalent dosing on the half-life is recommended.

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