How should I manage acute hyperactive delirium in a hospital setting with no reversible causes?

From the Guidelines

For acute hyperactive delirium without reversible causes in a hospital setting, I recommend a multimodal approach combining non-pharmacological and pharmacological interventions, prioritizing low-dose antipsychotics like olanzapine or quetiapine as first-line treatment, as supported by the most recent guidelines 1.

Non-Pharmacological Interventions

To manage acute hyperactive delirium, start with non-pharmacological strategies, including:

• Reorienting the patient frequently
• Ensuring the presence of family members when possible
• Maintaining a consistent care team
• Establishing normal sleep-wake cycles
• Providing adequate lighting during the day and darkness at night
• Minimizing noise
• Removing unnecessary medical equipment

Pharmacological Management

For pharmacological management, consider the following options:

• Low-dose antipsychotics: olanzapine 2.5-5mg orally/IM daily or quetiapine 25-50mg orally twice daily, as they appear less likely to be associated with extrapyramidal side effects (EPSEs) compared to first-generation antipsychotics 1
• Haloperidol 0.5-1mg IV/IM every 4 hours as needed, with a maximum of 5mg/24hrs in elderly patients
• For severe agitation threatening patient safety, consider short-term benzodiazepines like lorazepam 0.5-1mg IV/IM every 4 hours, but use cautiously as they may worsen delirium 1
• Dexmedetomidine infusion (0.2-0.7 mcg/kg/hr) may be considered in ICU settings for refractory cases

Monitoring and Safety

Regularly monitor vital signs, ECG (for QT prolongation with antipsychotics), and level of sedation to ensure patient safety and adjust treatment as needed. The use of pharmacological interventions should be limited to patients with distressing delirium symptoms or safety concerns, and medications should be used in the lowest effective dose and for a short period of time only 1.

From the Research

Management of Acute Hyperactive Delirium

• In a hospital setting with no reversible causes, managing acute hyperactive delirium requires a systematic approach 2
• The first step is to identify patients who develop or are at intermediate or high risk for delirium, using known patient-based and illness-based risk factors, including preexisting cognitive impairment 2
• Hospital systems can utilize established methods to assess and manage delirium in a standardized fashion, addressing the underlying cause/causes of delirium, which often involve medical conditions or medications 2

Pharmacological Treatment

• Antipsychotics, such as haloperidol, risperidone, olanzapine, and quetiapine, can be effective in managing delirium, with low-dose haloperidol being as effective as atypical antipsychotics in controlling delirium, but with a lower incidence of extrapyramidal adverse effects 3
• Valproic acid (VPA) is a potential alternative or adjunct treatment for hyperactive or mixed delirium, with multiple mechanisms of action, including effects on neurotransmitter modulation, neuroinflammation, oxidative stress, and transcription 4
• Benzodiazepines, antipsychotics, or ketamine can be used to treat hyperactive delirium with severe agitation, followed by airway protection, supportive measures, and cooling of hyperthermia 5

Non-Pharmacological Management

• The management of agitation secondary to hyperactive delirium should be proactive, rather than reactive, to avoid the inappropriate use of chemical and physical restraint 6
• Support and education for nurses caring for patients with delirium is essential to ensure optimal patient care and avoid staff burnout 6
• Tools such as the modified Richmond Agitation and Sedation Scale can aid in monitoring for changes in mental status that could indicate the development of delirium 2