From the Guidelines
The best approach for delirium in dementia is to use low-dose antipsychotics, such as olanzapine or quetiapine, for short durations, as they may offer benefit in the symptomatic management of delirium 1. When considering medication options, it's essential to weigh the potential benefits and harms, as antipsychotics are associated with clinically significant adverse effects, including mortality 1. The goal is to minimize symptoms, reduce patient distress, and improve quality of life while minimizing the risk of adverse effects.
Some key points to consider when using medications for delirium in dementia:
- Olanzapine, quetiapine, and aripiprazole may be beneficial in managing delirium symptoms, with a lower risk of extrapyramidal symptoms compared to first-generation antipsychotics 1
- Benzodiazepines, such as lorazepam, should be avoided except in cases of alcohol withdrawal delirium, due to their sedating effects and risk of falls 1
- Methylphenidate may be considered for hypoactive delirium without delusions or perceptual disturbances, but its use is not well-established in this context 1
- Non-pharmacological interventions should always be the first line of treatment, as medications can worsen symptoms or cause adverse effects
When using antipsychotics, it's crucial to:
- Start with the lowest possible dose
- Monitor closely for side effects, including sedation, falls, extrapyramidal symptoms, and increased stroke risk
- Regularly reassess the need for medication and discontinue as soon as possible once delirium resolves
- Identify and treat underlying causes of delirium, such as infections, medications, pain, or dehydration, as this is often more effective than symptom management with medications 1
From the Research
Medications for Delirium in Dementia
- The medications used to treat delirium in dementia include typical antipsychotics such as haloperidol, and atypical antipsychotics such as risperidone, olanzapine, and quetiapine 2, 3, 4.
- Low-dose haloperidol has been found to be as effective as atypical antipsychotics in managing delirium, with a lower incidence of extrapyramidal adverse effects 2.
- High-dose haloperidol is associated with a greater incidence of side effects, mainly parkinsonism, compared to atypical antipsychotics 2, 3.
- Risperidone, olanzapine, and aripiprazole have been found to be equally effective in managing delirium, with different side-effect profiles 3.
- Quetiapine has not been directly compared to haloperidol in the treatment of delirium, but has been found to be effective in managing delirium in some studies 2, 4.
Non-Pharmacological Interventions
- Non-pharmacological interventions, such as multicomponent interventions, have been found to be effective in preventing delirium in hospitalised patients 5.
- These interventions may include re-orientation, cognitive stimulation, sleep hygiene, attention to nutrition and hydration, oxygenation, medication review, assessment of mood, and bowel and bladder care 5.
- Multicomponent interventions have been found to reduce the incidence of delirium by 43% compared to usual care, with moderate-certainty evidence 5.
- The effectiveness of non-pharmacological interventions in preventing delirium in older people in institutional long-term care settings is uncertain, with limited evidence available 6.
Comparison of Medications
- The choice of medication for delirium in dementia should be based on the individual patient's needs and medical history, as well as the potential side effects of each medication 2, 3, 4.
- Haloperidol, risperidone, olanzapine, and quetiapine have been found to be effective in managing delirium, but may have different side-effect profiles 2, 3, 4.
- Further research is needed to determine the most effective medications for delirium in dementia, as well as the optimal dosing and duration of treatment 2, 3, 4.