What is the management of a 76-year-old male with acute stroke who has developed delirium overnight, with no prior history of dementia?

From the Guidelines

For a 76-year-old male with acute stroke now experiencing delirium without prior dementia, management should focus on both treating the delirium and optimizing stroke care, with a priority on non-pharmacological approaches and careful consideration of medication side effects, as recommended by the most recent guidelines 1.

Key Considerations

• Identify and address underlying causes of delirium, including infection, metabolic disturbances, medication effects, pain, constipation, urinary retention, and hypoxia.
• Ensure appropriate stroke management continues with antiplatelet therapy (aspirin 81-325mg daily) or anticoagulation if indicated.
• Implement non-pharmacological approaches for delirium, including:
  • Frequent reorientation
  • Maintaining day-night cycles
  • Ensuring hearing aids/glasses are used
  • Encouraging family presence
  • Minimizing disruptions
• Avoid physical restraints when possible.
• If medications are needed for severe agitation, consider low-dose haloperidol (0.5-1mg orally or IV every 4-6 hours as needed, maximum 5mg/day in elderly) or quetiapine (25mg once or twice daily), as suggested by recent guidelines 1.
• Avoid benzodiazepines except in alcohol withdrawal.
• Monitor for QT prolongation with antipsychotics.
• Ensure adequate hydration, nutrition, early mobilization, and DVT prophylaxis.

Rationale

The management of delirium in the context of acute stroke requires a multifaceted approach that prioritizes the patient's safety, comfort, and recovery. Non-pharmacological interventions are preferred due to their lower risk of adverse effects and potential to improve outcomes. When medications are necessary, careful selection and monitoring are crucial to minimize risks, particularly in elderly patients. The guidelines from 1 provide a comprehensive framework for managing delirium, emphasizing the importance of a tailored, multicomponent intervention package delivered by a multidisciplinary team. By following these recommendations and prioritizing the patient's overall well-being, healthcare providers can optimize outcomes for patients with acute stroke and delirium.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Delirium in a 76-Year-Old Male with Acute Stroke

• The patient's condition is associated with high rates of morbidity and mortality, and delirium is a significant concern in hospitalized medically ill patients 2.
• Quetiapine has been explored as a treatment option for delirium, with studies suggesting it may be an effective and safe agent for treating delirium in both general medicine and intensive care unit patients 2, 3.
• A study comparing quetiapine with haloperidol in the management of hyperactive delirium found that quetiapine may be equally as effective as haloperidol in treating the symptoms of hyperactive delirium in critically ill patients, with no mortality benefit 4.

Treatment Options

• Quetiapine has been shown to resolve symptoms of delirium more quickly than placebo and has equal efficacy compared to haloperidol and the atypical antipsychotic amisulpride 2.
• Low doses of haloperidol and quetiapine appear to be safe, without an increase in risk of sudden cardiac death, in-hospital mortality, or one-year mortality in carefully monitored patients 3.
• However, a study found that haloperidol and risperidone users had a higher mortality risk than quetiapine users in post-stroke elderly patients, suggesting that quetiapine may pose less mortality risk than risperidone and haloperidol at doses higher than 0.5 defined daily dose (DDD) 5.

Considerations

• The clinical characteristics of patients with delirium who did and did not receive antipsychotic therapy were not different, and in-hospital mortality, ventricular arrhythmia, and one-year mortality among hospital survivors were not different in patients with delirium irrespective of whether or not they received antipsychotics 3.
• A study in pediatric intensive care unit (PICU) patients with delirium found that patients treated with haloperidol or quetiapine showed no short-term improvement in delirium screening scores after starting treatment when compared with untreated, propensity score-matched patients 6.