Management of acute confusion (delirium) in older people

Delirium is an acute confusional state characterized by an alteration of consciousness with reduced ability to focus, sustain or shift attention. Delirium develops over a short period of time (usually hours to days) tends to fluctuate during the course of the day and worsens at night. It is commonly associated with medical and physical conditions, and with increasing age.

Do

  • Provide a quiet environment and use adequate lighting levels appropriate for the time of the day
  • Give regular cues to re-orientate, use clocks and calendars
  • Ensure use of hearing aids and glasses if needed
  • Give consistent nursing care with a gentle, calm approach
  • Provide pain relief by giving regular paracetamol if needed
  • Prevent dehydration by encouraging the patient to drink or use intravenous fluids if necessary. Prevent constipation
  • Encourage mobility and engagement with group activities
  • Ensure a good sleep pattern
  • Encourage visits from family and friends who may help calm the patient down and bring some familiar objects and pictures from home
  • For medical inpatients, consider referral to liaison

Don't

  • Transfer between wards/units
  • Use physical restraint or argue with patients
  • Use anticholinergic drugs and keep drug intervention to a minimum
  • Catheterise unless essential, as this can precipitate delirium.

Patients who wander require a close observation in a safe environment using as few restrictions as possible acting in the best interest of the patient. This may include an assessment of risk, remedying any cause of agitation such as thirst, pain, need for toilet or when required trying a distraction technique.

Frequent complications of delirium are:

Falls, Pressure sores, Malnutrition, Continence problems, Functional impairment

Drug intervention

Drug intervention is often unnecessary.

Some elderly people present with a hypoactive form of delirium where the patient is quiet, withdrawn and may not need sedation. In these patients detection is also important because of the high morbidity and mortality of delirium.

It is important to remember the following basic principles:

  • Use of sedatives or major tranquilisers should be kept to a minimum
  • Use one drug only if possible, starting with the lowest dose and titrating upwards if necessary.
  • All medication should be reviewed as frequently as possible.
  • Baseline ECG is recommended prior to treatment with haloperidol in all patients, especially in the elderly and patients with a positive personal or family history of cardiac disease or abnormal findings on cardiac clinical examination.
  • If using any sedatives, tail off any sedation after 24-48 hours if possible

Sedation may be used when carrying out essential investigations or treatment, to prevent the patient endangering themselves or to relieve distress in an agitated or hallucinating patient

Acute agitation

  • Tailor dose according to age, body size and degree of sedation, titrate dose to effect
  • Review all medication at least every 24 hours, medication should usually be discontinued 7-10 days after symptoms resolve

If any of the following are suspected:

  • Withdrawal of alcohol or sedatives
  • Anticholinergic toxicity
  • Hepatic failure
  • Heart disease
  • Any features of Parkinson's disease or extra-pyramidal side-effects (EPSE)
  • Dementia with Lewy Bodies (DLB) (see below)
  • Neuroleptic malignant syndrome.

Oral lorazepam 500 micrograms to 1mg single dose (if patient refuses oral treatment consider I/M lorazepam 500 micrograms to 1mg single dose). Repeat after 30 minutes if necessary. Maximum 3mg in 24 hours:

  • Sedation in 30-45 minutes, peak effect in 1-3 hours

Lorazepam is not to be used in patients with or at risk of respiratory depression

Monitor response

If not considered to be:

  • Due to alcohol or drugs
  • Due to the conditions listed above.
  • Patients with or at risk of respiratory depression

If any parkinsonism is present avoid haloperidol.

Do not use haloperidol in neuroleptic-naïve patients or if DLB is suspected.

Oral haloperidol 500 micrograms to 1mg single dose (if patient refuses oral treatment consider I/M haloperidol 500 micrograms to 1mg single dose)

Wait 45-60 minutes and repeat up to four hourly to a maximum dose of 6mg/24 hours:

  • Sedation in 1 hour, peak effect in 2-6 hours (oral)
  • Peak effect in 20-40 minutes (I/M)
  • Baseline ECG Recommended

Monitor response

Monitor for EPSE:

  • Parkinsonian side-effects - reduce dose of haloperidol or change to lorazepam.
  • Acute dystonia (rare in the elderly). Uncontrolled muscle spasm, often in the head and neck (torticollis) or eyes (oculogyric crisis). Patient may be unable to swallow or speak clearly. In extreme cases the back may arch or the jaw dislocate. Can be painful and frightening. Stop haloperidol and prescribe procyclidine 5mg oral or IM (patient may be unable to swallow oral dose). Effective in 20 minutes. Repeat if necessary, up to a maximum of 30mg in 24 hours.

Dementia with Lewy Bodies (DLB): patients are extremely sensitive to antipsychotic medication and this may result in a sudden onset of EPSE, profound confusion, deterioration and death. DLB accounts for approx. 15% of cases of dementia among people aged over 65 (overall population incidence 0.75%). Characteristic symptoms are dementia, marked fluctuation of cognitive ability, early and persistent visual hallucinations and spontaneous motor features of Parkinsonism.

Sub-acute or chronic agitation

Specialist referral recommended.

The following options can be considered:

  • For restlessness, agitation or night-time disturbance:
    • Valproic acid 250mg twice daily (unlicensed)
    • Trazodone 50mg at night, increasing if necessary to maximum 300mg per day
  • For “sundowning":
    • Trazodone 50 to 100mg in the early afternoon
  • For delusions, paranoia or hallucinations:
    • Quetiapine start 25mg daily and increase by 25-50mg/day (give in divided doses). Normal dose 200mg per day (in divided doses).Risk of hypotension – monitor BP and pulse. Caution: Dementia with Lewy Bodies (see above)

Consider the presence of depression and treat accordingly.

 

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