Delirium Management

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Core management

  • Provide immediate medical care (Airway, Breathing, Circulation).
  • Safely manage any aggression (see section in Part 2 of this guide).
  • Keep the person safe, encourage fluids.
  • Urgently refer and transport to District Hospital emergency department.
  • The mainstay of treatment is identifying and treating the underlying medical or surgical (organic) cause.
  • If transfer is delayed, investigate and treat possible underlying general medical condition.
  • Explain to the person and family what is happening (use the patient information leaflet in Part 6).

Refer to clinician in emergency department – ask medics for a delirium workup / confusion screen.

If after full investigation and treatment the person has persistent psychiatric symptoms, then carefully review the patient. Refer to tertiary care if needed.

The mental health team should not be in charge of the care of someone with suspected delirium but should liaise with the treating specialty (e.g. medicine, surgery, obstetrics) and offer advice on management of agitation or aggression if needed.

The role of psychiatric treatment is to control the behavioural disturbances in order to allow identification and management of the underlying cause (e.g. infections, alcohol withdrawal, hypoglycaemia etc.)

Psychosocial

Advice for managing a delirious patient:

  • Keep in a quiet room away from loud noises or excitement.
  • Reassure, as they may be feeling frightened.
  • Remind them of who you are, where they are, what the time is and what has happened to them.
  • Care for by one person (if possible). This will help them feel less confused. If a nurse is not able to do this, then a family member can do this job.

If the person is aggressive and agitated even after doing these things, you may have to prescribe some medication such as low-dose haloperidol.

Medication

For behavioural disturbances or aggression give short course of low dose of antipsychotic medication:

1st line: Oral Haloperidol 2.5mg bd for 7 days or until agitation / confusion resolves.

2nd line: If the patient is refusing oral medications, use IM Haloperidol 2.5 – 5mg bd until sufficiently improved to accept medications orally.

3rd line: If agitation is very severe despite the above measures, consider adding Diazepam 5 – 10mg PO or slow IV push for short time or until less agitated (3-5 days).

Reserve Diazepam use for cases where agitation is posing a very high risk, Diazepam can worsen the condition. Intravenous or high dose Diazepam can cause respiratory depression/ distress.

Review, Monitoring and Follow-up

  • Monitoring of physical condition at least every 8 hours until stable.
  • Mental Health review every 24-48 hours. If agitation is severe, review the patient more regularly.
  • Once symptoms have resolved, reduce and stop the antipsychotics.

Follow-Up

  • After discharge. arrange follow up in 5-7 days’ time to ensure patient remains stable.