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9 - Delirium

from Part III - Specific treatments

Published online by Cambridge University Press:  12 May 2010

By
Laura Gage  and
David K. Conn
Edited by
Peter Tyrer  and
Kenneth R. Silk
Laura Gage
Affiliation:
Department of Psychiatry University of Toronto Toronto, ON Canada
David K. Conn
Affiliation:
University of Toronto Toronto, ON Canada
Peter Tyrer
Affiliation:
Imperial College of Science, Technology and Medicine, London
Kenneth R. Silk
Affiliation:
University of Michigan, Ann Arbor
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Summary

Editor's note

Delirium is one of the forgotten areas of therapeutics. It is observed frequently, often misinterpreted and misunderstood, but often mercifully disappears just as uncertainty about what to do gets stronger. This probably explains the relative paucity of evidence available about preferred treatments; delirium is a prelude to focused intervention rather than a clarion call for action. This chapter nonetheless indicates the beginnings of an evidence base for intervention that is of definite value.

Introduction

Delirium is associated with increased rates of mortality and medical complications, prolonged hospitalization, as well as cognitive and functional impairment. Symptoms of delirium can also cause significant distress and discomfort to both patients and their families. Unfortunately, delirium is commonly underdiagnosed by physicians. Recognition and appropriate treatment of delirium is essential to minimize associated morbidity.

The treatment of delirium is to tackle the underlying cause. Identifying underlying aetiologies and their correction should always be foremost in the clinician's mind. The common causes include infection, drug intoxication, renal or hepatic insufficiency, vascular disease affecting the brain, and electrolyte disturbance, and the prevalence of the condition varies from 10% in young hospitalized medical patients to 80% in those who are terminally ill (Brown & Boyle, 2002).

Delirium may cause agitation or psychotic symptoms, which puts patients or others at risk, affects their treatment, or may cause significant distress. In addition to environmental interventions, pharmacological treatment may be necessary to control these symptoms.

Antipsychotics have been the mainstay of treatment for agitation and psychotic symptoms in delirium.

Type
Chapter
Information
Cambridge Textbook of Effective Treatments in Psychiatry , pp. 173 - 186
Publisher: Cambridge University Press
Print publication year: 2008

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References

Adams, F., Fernandez, F. & Andersson, B. (1986). Emergency pharmacotherapy of delirium in the critically ill cancer patient. Psychosomatics, 27 (Suppl. 1), 33–7.Google Scholar
Aizawa, K., Kanai, T., Saikawa, Y.et al. (2002). A novel approach to the prevention of post-operative delirium in the elderly after gastrointestinal surgery. Surgery Today, 32, 310–14.Google Scholar
Akechi, T., Uchitomi, Y., Okamura, H.et al. (1996). Usage of haloperidol for delirium in cancer patients. Support Care Cancer, 4, 390–2.Google Scholar
American Psychiatric Association (1999). Practice guideline for the treatment of patients with delirium. American Journal of Psychiatry, 156 (May suppl.), 1–20.
Bayindir, O., Akpinar, B., Can, E.et al. (2000). The use of 5-HT3 receptor antagonist ondansetron for the treatment of postcardiotomy delirium. Journal of Cardiothoracic and Vascular Anesthesia, 14, 288–92.Google Scholar
Blitzstein, S. M. & Brandt, G. T. (1997). Extrapyramidal symptoms from intravenous haloperidol in the treatment of delirium. American Journal of Psychiatry, 154, 1474–5.Google Scholar
Breitbart, W., Marotta, R., Platt, M.et al. (1996). A double-blind trial of haloperidol, chlorpromazine and lorazepam in the treatment of delirium in hospitalized AIDS patients. American Journal of Psychiatry, 153, 231–7.Google Scholar
Breitbart, W., Tremblay, A. & Gibson, C. (2002). An open trial of olanzapine for the treatment of delirium in hospitalized cancer patients. Psychosomatics, 43, 175–82.Google Scholar
Britton, A. & Russell, R. (2004). Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment. Cochrane Database of Systematic Reviews, 2, CD000395.Google Scholar
Brown, T. M. & Boyle, M. F. (2002). Delirium. British Medical Journal, 325, 644–7.Google Scholar
Budd, S. & Brown, W. (1974). Effect of a reorientation technique on postcardiotomy delirium. Nursing Research, 23, 341–8.Google Scholar
Carnes, M., Howell, T., Rosenberg, M.et al. (2003). Physicians vary in approaches to the clinical management of delirium. Journal of the American Geriatrics Society, 51, 234–9.Google Scholar
Chatham, M. A. (1978). The effect of family involvement on patients' manifestations of postcardiotomy psychosis. Heart & Lung, 7, 995–9.Google Scholar
Cole, M. G. (2004). Delirium in elderly patients. American Journal of Geriatric Psychiatry, 12, 7–21.Google Scholar
Cole, M. G., Primeau, F. J., Bailey, R. F.et al. (1994). Systematic intervention for elderly inpatients with delirium: a randomized trial. Canadian Medical Association Journal, 151, 965–70.Google Scholar
Cole, M. G., McCusker, J., Bellavance, F.et al. (2002). Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trail. Canadian Medical Association Journal, 167, 753–9.Google Scholar
Coppen, A., Gupta, R., Montgomery, S.et al. (1976). Mianserin hydrochloride: a novel antidepressant. British Journal of Psychiatry, 129, 342–5.Google Scholar
Davis, J. M., Janicak, P. G., Sakkas, P.et al. (1991). Electroconvulsive therapy in the treatment of the neuroleptic malignant syndrome. Convulsive Therapy, 7, 111–20.Google Scholar
Dudley, W. H. & Williams, J. G. (1972). Electroconvulsive therapy in delirium tremens. Comprehensive Psychiatry, 13, 357–60.Google Scholar
Dugovic, C. & Adrien, J. (1991). 5-HT receptors involved in sleep regulation. In Biological Psychiatry, Vol. 2, ed. Racagni, G. K., Brunllo, N. & Fukuda, T., pp. 710–12. Amsterdam: Elsevier.
Fernandez, F. & Levy, J. K. (1989). Management of delirium in terminally ill AIDS patients. International Journal of Psychiatry in Medicine, 19, 165–72.Google Scholar
Fischer, P. (2001). Successful treatment of nonanticholinergic delirium with a cholinesterase inhibitor. Journal of Clinical Psychopharmacology, 21, 118.Google Scholar
Foreman, M. D., Mion, L. C., Tryostad, L.et al. (1999). Standard of practice protocol: acute confusion/delirium. Geriatric Nursing, 20, 147–52.Google Scholar
Gagnon, B., Low, G., Schreier, G.et al. (2005). Methylphenidate hydrochloride improves cognitive function in patients with advanced cancer and hypoactive delirium: a prospective clinical study. Journal of Psychiatry and Neuroscience, 30, 100–7.Google Scholar
Gustafson, Y., Brannstrom, B., Berggren, D.et al. (1991). A geriatric-anesthesiologic program to reduce acute confusional states in elderly patients treated for femoral neck fractures. Journal of the American Geriatrics Society, 39, 655–62.Google Scholar
Hales, R. E. & Yudofsky, S. C., ed. (2003). Textbook of Clinical Psychiatry. American Psychiatric Publishing Inc.
Han, C. & Kim, Y. (2004). A double-blind trial of risperidone and haloperidol for the treatment of delirium. Psychosomatics, 45, 297–301.Google Scholar
Hanania, M. & Kitain, E. (2002). Melatonin for treatment and prevention of post-operative delirium. Anesthesia and Analgesia, 94, 338–9.Google Scholar
Horikawa, N., Yamazaki, T., Miyamoto, K.et al. (2003). Treatment for delirium with risperidone: results of a prospective open trial with 10 patients. General Hospital Psychiatry, 25, 289–92.Google Scholar
Jacobi, J., Fraser, G. L., Coursin, D. B.et al. (2002). Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Critical Care Medicine, 30, 119–41.Google Scholar
Kalisvaart, C. J., Boelaarts, L., DeJonghe, J. F.et al. (2004). Successful treatment of three elderly patients suffering from prolonged delirium using the cholinesterase inhibitor rivastigmine. Nederlands Tijdschrift voor Geneeskunde, 148, 1501–4 (in Dutch).Google Scholar
Kim, K. Y., Bader, G. M., Kotlyar, V.et al. (2003). Treatment of delirium in older adults with quetiapine. Journal of Geriatric Psychiatry and Neurology, 16, 29–31.Google Scholar
Kim, K., Pae, C., Chae, J.et al. (2001). An open pilot trial of olanzapine for delirium in the Korean population. Psychiatry and Clinical Neurosciences, 55, 515–19.Google Scholar
Leso, L. & Schwartz, T. L. (2002). Ziprasidone treatment of delirium. Psychosomatics, 43, 61–2.Google Scholar
Liu, C., Juang, Y., Liang, H.et al. (2004). Efficacy of risperidone in treating the hyperactive symptoms of delirium. International Clinical Psychopharmacology, 19, 165–8.Google Scholar
Marshall, R. J. (1983). The pharmacology of mianserin – an update. British Journal of Clinical Pharmacology, 15, 263S–8S.Google Scholar
Meagher, D. J., O'Hanlon, D., O'Mahoney, E. & Casey, P. R. (1996). The use of environmental strategies and psychotropic medication in the management of delirium. British Journal of Psychiatry, 168, 512–15.Google Scholar
Menza, M. A., Murray, G. B., Holmes, V. F.et al. (1987). Decreased extrapyramidal symptoms with intravenous haloperidol. Journal of Clinical Psychiatry, 48, 278–80.Google Scholar
Menza, M. A., Murray, G. B., Holmes, V. F.et al. (1988). Controlled study of extrapyramidal reactions in the management of delirious, medically ill patients: intravenous haloperidol versus intravenous haloperidol plus benzodiazepines. Heart and Lung, 17, 238–41.Google Scholar
Meyers, B. J. & Ojen, R. L. (2004). The treatment with methylphenidate of demoralisation, apathy and hypoactive delirium in patients with somatic illness. Nederlands Tijdschrift voor Geneeskunde, 148, 1738–41 (in Dutch).Google Scholar
Milisen, K., Foreman, M. D., Abraham, I. L.et al. (2001). A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients. Journal of the American Geriatrics Society, 49, 523–32.Google Scholar
Morita, T., Otani, H., Tsunoda, J.et al. (2000). Successful palliation of hypoactive delirium due to multi-organ failure by oral methylphenidate. Support Care Cancer, 8, 134–7.Google Scholar
Moulaert, P. (1989). Treatment of nonspecific delirium with IV haloperidol in surgical intensive care patients. Acta Anaesthesiologica Belgica, 40, 183–6.Google Scholar
Nakamura, J., Uchimura, N. & Yamada, S. (1997a). Does plasma free-3-methoxy-4-hydroxyphenyl (ethylene) glycol increase in the delirious state? A comparison of the effects of mianserin and haloperidol on delirium. International Clinical Psychopharmacology, 12, 147–52.Google Scholar
Nakamura, J., Uchimura, N., Yamada, S.et al. (1997b). Mianserin suppositories in the treatment of post-operative delirium. Human Psychopharmacology, 12, 595–9.Google Scholar
Okamoto, Y., Matsuoka, Y., Sasaki, T.et al. (1999). Trazodone in the treatment of delirium. Journal of Clinical Psychopharmacology, 19, 280–2.Google Scholar
Olofsson, S. M., Weitzner, M. A., Valentine, A. D.et al. (1996). A retrospective study of the psychiatric management and outcome of delirium in the cancer patient. Support Care Cancer, 4, 351–7.Google Scholar
Parellada, E., Baeza, I., Pablo, J.et al. (2004). Risperidone in the treatment of patients with delirium. Journal of Clinical Psychiatry, 65, 348–53.Google Scholar
Pinder, R. M. (1983). Antidepressants and α-adrenoreceptors. In Clinical Pharmacology in Psychiatry: Bridging the Experimental–Therapeutic Gap, ed. Gram, L., pp. 268–87. London: Macmillan.
Platt, M. M., Breitbart, W., Smith, M.et al. (1994). Efficacy of neuroleptics for hypoactive delirium. Journal of Neuropsychiatry, 6, 66–7.Google Scholar
Ravona-Springer, R., Ramit, M. D., Ornah, T.et al. (1998). Delirium in elderly patients treated with risperidone: a report of three cases. Journal of Clinical Psychopharmacology, 18, 171–2.Google Scholar
Resnick, M. & Burton, B. T. (1984). Droperidol vs. haloperidol in the initial management of acutely agitated patients. Journal of Clinical Psychiatry, 45, 298–9.Google Scholar
Riker, R. R., Fraser, G. L., Gilles, L.et al. (1997). Movement disorders associated with withdrawal from high-dose intravenous haloperidol therapy in delirious ICU patients. Chest, 111, 1778–81.Google Scholar
Robertson, B., Karlsson, I., Eriksson, L.et al. (1996). An atypical neuroleptic drug in the treatment of behavioural disturbances and psychotic symptoms in elderly people. Dementia, 7, 142–6.Google Scholar
Sanders, K. M., Stern, T. A., O'Gara, P. T.et al. (1992). Delirium during intra-aortic balloon pump therapy. Psychosomatics, 33, 35–44.Google Scholar
Sasaki, Y., Matsuyama, T., Inoue, S.et al. (2003). A prospective, open-label, flexible-dose study of quetiapine in the treatment of delirium. Journal of Clinical Psychiatry, 64, 1316–21.Google Scholar
Scheftner, W. A. & Shulman, R. B. (1992). Treatment choice in neuroleptic malignant syndrome. Convulsive Therapy, 8, 267–79.Google Scholar
Schwartz, T. L. & Masand, P. S. (2000). Treatment of delirium with quetiapine. Primary Care Companion Journal of Clinical Psychiatry, 2, 10–12.Google Scholar
Seneff, M. G. & Mathews, R. A. (1995). Use of haloperidol infusions to control delirium in critically ill adults. Annals of Pharmacotherapy, 29, 690–3.Google Scholar
Sipahimalani, A., Sime, R. M. & Masand, P. S. (1997). Treatment of delirium with risperidone. International Journal of Geriatric Psychopharmacology, 1, 24–6.Google Scholar
Sipahimalani, A. & Masand, P. S. (1998). Olanzapine in the treatment of delirium. Psychosomatics, 39, 422–30.Google Scholar
Skrobik, Y. (2002). Haloperidol should be used sparingly. Critical Care Medicine, 30, 2613–14.Google Scholar
Skrobik, Y. K., Bergeron, N., Dumont, M.et al. (2004). Olanzapine vs haloperidol: treating delirium in a critical care setting. Intensive Care Medicine, 30, 444–9.Google Scholar
Someya, T., Endo, , Hara, T.et al. (2001). A survey on the drug therapy for delirium. Psychiatry and Clinical Neurosciences, 55, 397–401.Google Scholar
Stiefel, F., Fainsinger, R. & Bruera, E. (1992). Acute confusional states in patients with advanced cancer. Journal of Pain and Symptom Management, 7, 94–8.Google Scholar
Tauscher, J., Tauscher-Wisniewski, D. & Kasper, S. (2000). Treatment of patients with delirium. American Journal of Psychiatry, 157, 1711.Google Scholar
Tei, Y., Morita, T., Inoue, S.et al. (2004). Torsades de pointes caused by a small dose of risperidone in a terminally ill cancer patient. Psychosomatics, 45, 450–1.Google Scholar
Thomas, H., Schwartz, E. & Petrilli, R. (1992). Droperidol versus haloperidol for chemical restraint of agitated and combative patients. Annals of Emergency Medicine, 21, 407–13.Google Scholar
Trzepacz, P. T., Ho, V. & Mallavarapu, H. (1996). Cholinergic delirium and neurotoxicity associated with tacrine for Alzheimer's dementia. Psychosomatics, 37, 299–301.Google Scholar
Trzepacz, P. T. (2000). Is there a final common neural pathway in delirium? Focus on acetylcholine and dopamine. Seminars in Clinical Neuropsychiatry, 5, 132–48.Google Scholar
Uchiyama, M., Tanaka, K., Isse, K.et al. (1996). Efficacy of mianserin on symptoms of delirium in the aged: an open trial study. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 20, 651–6.Google Scholar
Mast, R. C. & Fekkes, D. (2000). Serotonin and amino acids: partners in delirium pathophysiology. Seminars in Clinical Neuropsychiatry, 5, 125–31.Google Scholar
Wengel, S. P., Roccaforte, W. H. & Burke, W. J. (1998). Donepezil improves symptoms of delirium in dementia: implications for future research. Journal of Geriatric Psychiatry and Neurology, 11, 159–61.Google Scholar
Wengel, S. P., Burke, W. J. & Roccaforte, W. H. (1999). Donepezil for post-operative delirium associated with Alzheimer's disease. Journal of the American Geriatric Society, 47, 379–80.Google Scholar
Williams, M. A., Campbell, E. B., Raynor, W. J.et al. (1985). Reducing acute confusional states in elderly patients with hip fractures. Research in Nursing and Health, 8, 329–37.Google Scholar
Young, C. C. & Lujan, E. (2004). Intravenous ziprasidone for treatment of delirium in the intensive care unit. Anesthesiology, 101, 794–5.Google Scholar

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  • Delirium
    • By Laura Gage, Department of Psychiatry University of Toronto Toronto, ON Canada, David K. Conn, University of Toronto Toronto, ON Canada
  • Edited by Peter Tyrer, Imperial College of Science, Technology and Medicine, London, Kenneth R. Silk, University of Michigan, Ann Arbor
  • Book: Cambridge Textbook of Effective Treatments in Psychiatry
  • Online publication: 12 May 2010
  • Chapter DOI: https://doi.org/10.1017/CBO9780511544392.011
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  • Delirium
    • By Laura Gage, Department of Psychiatry University of Toronto Toronto, ON Canada, David K. Conn, University of Toronto Toronto, ON Canada
  • Edited by Peter Tyrer, Imperial College of Science, Technology and Medicine, London, Kenneth R. Silk, University of Michigan, Ann Arbor
  • Book: Cambridge Textbook of Effective Treatments in Psychiatry
  • Online publication: 12 May 2010
  • Chapter DOI: https://doi.org/10.1017/CBO9780511544392.011
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To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

  • Delirium
    • By Laura Gage, Department of Psychiatry University of Toronto Toronto, ON Canada, David K. Conn, University of Toronto Toronto, ON Canada
  • Edited by Peter Tyrer, Imperial College of Science, Technology and Medicine, London, Kenneth R. Silk, University of Michigan, Ann Arbor
  • Book: Cambridge Textbook of Effective Treatments in Psychiatry
  • Online publication: 12 May 2010
  • Chapter DOI: https://doi.org/10.1017/CBO9780511544392.011
Available formats
×