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CheneyHsiung
Mon 5th August '13, 11:34pm
Delirium is a common neuropsychiatric symptom in patients with advanced terminal diseases. It is defined as an acquired syndrome of disordered consciousness and cognition that develops over a short period of hours or days. It often worse at night.

Hall mark features of delirium include an acute onset and fluctuating course;inattention, with difficulty focusing and easy distraction;an altered level of consciousness;and cognitive impairment, impaired memory, disorientation, delusions, and/or hallucinations.

There are three subtypes of delirium:



[*=1]Hyperactive (e.g., hyperaroused, agitated), which is marked by hypervigilance, agitation, restlessness, and hallucinations;
[*=1]Hypoactive (e.g., hypoaroused, hypoalert), which is marked by slow psychomotor activity, lethargy, and apathy (it is often mistaken for sedation due to opioids in the final hours of life);
[*=1]Mixed (e.g., fluctuates between hyperactive and hypoactive types).


Of note, hypoactive delirium is more common than the other two subtypes, affecting up to 80% of patients with delirium. Terminal delirium occurs in the final hours to weeks of life. To some extent, terminal delirium is experienced by most if not all dying patients.

The goal of managing delirium is to prevent or reverse the course when possible. Although about one-third of delirium episodes are reversible, it is often not reversible in the last 24 to 48 hours of life.

Haloperidol is often the first-line treatment for delirium.



TABLE 12-6 Medications to Manage Delirium


Medication
Approximate Daily Dosea
Routeb


Neuroleptics
 
 


Haloperidol
0.5–5 mg every 2–12 h
po, IV, SQ, IM


Thioridazine
10–75 mg every 4–8 h
po


Chlorpromazne
12.5–50 mg every 4–12 h
po, IV, IM


Droperidol
0.625-2.5 mg every 48 h
IV, IM


Atypical neuroleptics
 
 


Olanzapine
2.5–20 mg every 12–24 h
po


Risperidone
1–3 mg every 12–24 h
po


Quetiapine
25–200 mg every 12–24 h
po


Benzodiazepines
 
 


Lorazepam
0.5–2 mg every 1–4 h
po, IV, IM


Midazolam
30–100 mg every 24 h
IV, SQ


Anesthetics
 
 


Propofol
10–70 mg every h (up to 200–400 mg/h)
IV


a Parenteral doses are generally twice as potent as oral doses.


b Intramuscular injections should be avoided if repeated use becomes necessary. Intravenous infusions or bolus injections should be administered slowly. Oral forms of medications are preferred. Subcutaneous infusions are generally accepted modes of drug administration in the terminally ill.


IM = intramuscularly; IV, intravenously; po = by mouth; SQ, subcutaneously.


Source: Brayman Y, Breitbart W, Friedlander M. Delirium in Palliative Care. Psychiatr Times 2004;18(4):183-185. Copyright 2009, Psychiatric Times, CMPMedica. All rights reserved.

CheneyHsiung
Sat 15th February '14, 7:24pm
Well, this thread is important for the sedation and delirium in ICU, I think.