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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.
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.
Falls, Pressure sores, Malnutrition, Continence problems, Functional impairment
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Some elderly people present with a hypoactive form of delirium where the patient is quiet, withdrawn and may not need sedation.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:
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
If any of the following are suspected:
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:
Lorazepam is not to be used in patients with or at risk of respiratory depression
Monitor response
If not considered to be:
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:
Monitor response
Monitor for EPSE:
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.
Specialist referral recommended.
The following options can be considered:
Consider the presence of depression and treat accordingly.