Short term confusion and changes in cognition
Symptoms fluctuate in intensity over a 24 hour period
DSM-IV-TR Diagnostic Criteria for Delirium due to
Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attention.
A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established or evolving dementia.
The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.
– “ICU Psychosis”– “Toxic Psychosis”– “Posttraumatic Amnesia”– “Acute Confusional State”
– Agitated, psychotic patient not representative
of majority of patients with mixed or hypoactive symptom profile
(especially visual), illusions, metamorphopsias
– Word-finding difficulty– Dysgraphia– Altered semantic content
• 10 – 15% of elderly persons are delirious
– Another 10 – 40% are diagnosed with delirium
• 3 – month mortality rate of patients with an
• Elderly patients with delirium while
hospitalized have 20 – 75% mortality rate during that hospitalization
• Need information about baseline mentation
• Formal Mini Mental Status Exam (MMSE) can be
helpful but does not differentiate from dementia
• Generalized slowing• Improvement in background rhythm parallels
– Heat stroke– Hypothermia– Electrocution– Burn
• After removal or treatment of causative
factor, symptoms of delirium usually recede over 3 – 7 days
• Older the patient and the longer delirious,
• Restraints may be needed to avoid self
– Natural day/night lighting, nightlights
– Neuroleptic most often chosen for delirium– p.o., I.M., or I.V.
• I.V. route not FDA approved and with warning regarding QTc
• I.V. and I.M. route twice as potent as p.o.
– Reduces agitation, aids in cognition and psychotic
– Underlying cause must still be addressed
• QTc < 450 = OK• QTc : 450 – 500 = caution• QTc > 500 = use something else p.o. or I.M.
– Dosages up 1200 mg in 24 hr given safely in
– 5 mg IM Q4 hr prn (often given with 50 mg
benadryl and 2 mg ativan: want to avoid both in delirium)
– Like Haldol, has low anticholinergic activity
- Theoretical concern with anticholinergic activity
- Acute agitation: 10 mg IM Q2 hr (x2 in 24 hr) –
- Don’t give with benzos (reports of death – more than IV
– 50 mg p.o. BID, 100 mg p.o. QHS and 50 mg
– Advantage in pts with parkinsons or lewy
– Check EKG – wouldn’t use if >450
• Problem is inconsistent results on agitation
– In acute agitation: 20 mg I.M. Q2 hr (x2)
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