From the Guidelines
For an agitated patient with intellectual impairment and delirium who is disturbing other patients and has already received diazepam, I recommend administering low-dose antipsychotics such as quetiapine 25-50mg orally. This recommendation is based on the most recent and highest quality study available, which suggests that quetiapine may offer benefit in the symptomatic management of delirium 1. The use of quetiapine is preferred over other antipsychotics such as haloperidol due to its lower risk of extrapyramidal side effects, particularly in patients with Parkinson's disease or Lewy body dementia. Some key points to consider when administering quetiapine include:
- Starting with a low dose of 25mg orally and titrating as needed to minimize side effects
- Monitoring vital signs closely after administration, particularly for QT prolongation and orthostatic hypotension
- Implementing non-pharmacological interventions such as reorientation techniques, ensuring adequate lighting, maintaining a quiet environment, and having familiar objects nearby to help manage delirium symptoms
- Identifying and treating the underlying cause of delirium, such as infection, metabolic disturbance, or medication effect, as the definitive management. It's also important to note that benzodiazepines, such as diazepam, should be used with caution in patients with delirium due to their potential to worsen confusion and cause respiratory depression, and their use should be limited to patients who have distressing delirium symptoms or safety concerns 1.
From the FDA Drug Label
Diazepam is indicated for the management of anxiety disorders or for the short- term relief of the symptoms of anxiety. In acute alcohol withdrawal, diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis
The patient has already had diazepam. For agitated patient with intellectual impairment and delirium, diazepam may be useful for the symptomatic relief of acute agitation and delirium.
- Diazepam can be considered for the management of agitation and delirium in this patient, given its indication for acute alcohol withdrawal and relief of acute agitation and delirium tremens 2.
From the Research
Agitation and Delirium Management
- Agitation is a psychomotor disturbance characterized by a marked increase in motor and psychological activity in a patient, often accompanied by other mental disorders such as severe anxiety and delirium 3.
- The management of agitation and delirium is crucial, as these conditions can interfere with patient care and have adverse consequences on prognosis 3.
Treatment Options
- Haloperidol is frequently used for acute agitation, but second-generation antipsychotics such as olanzapine and ziprasidone show similar efficacy and improved safety and tolerability 4.
- A study comparing intramuscular haloperidol and other short-acting injectable antipsychotics found that olanzapine and ziprasidone may be effective alternatives for acute agitation in adults admitted to an inpatient psychiatry unit 4.
- For terminal agitation, haloperidol with as-needed benzodiazepines, chlorpromazine, or levomepromazine may be effective and safe 5.
Benzodiazepines for Agitation
- Benzodiazepines may be used in patients with agitated delirium, particularly in the setting of terminal delirium or delirium tremens 6.
- A study found that lorazepam in combination with haloperidol as rescue medication was more effective than haloperidol alone for the management of persistent restlessness/agitation in patients with terminal delirium 6.
- Benzodiazepines should be used with caution, as they can precipitate or worsen delirium and over-sedation 6.
Pharmacological Treatment
- The traditionally accepted treatment for agitated psychotic patients involves the use of a typical antipsychotic, such as haloperidol, often in combination with a benzodiazepine like lorazepam 7.
- Atypical antipsychotics, such as olanzapine and ziprasidone, have gained acceptance as first-line treatments for psychotic disorders and may be useful in the emergency setting 7.