What is the role of Seroquel (quetiapine) in the management of delirium?

Quetiapine in the Management of Delirium

Quetiapine may offer benefit in the symptomatic management of delirium, particularly when other antipsychotics are contraindicated or ineffective. 1

Assessment and Diagnosis

Delirium diagnosis should be made by trained healthcare professionals using clinical assessment based on DSM or ICD criteria, rather than relying solely on screening tools 1. Key features to assess include:

• Fluctuating consciousness
• Impaired cognition
• Perceptual disturbances
• Behavioral changes
• Psychomotor activity changes (hyperactive, hypoactive, or mixed)

Management Algorithm

Step 1: Address Underlying Causes

Before initiating pharmacological treatment, identify and address potentially reversible causes:

• Discontinue implicated medications
• Treat infections if appropriate
• Correct electrolyte abnormalities (particularly calcium, magnesium)
• Address metabolic disturbances
• Manage opioid-induced neurotoxicity through opioid rotation 1

Step 2: Non-Pharmacological Interventions

Implement non-pharmacological approaches first, though evidence for their efficacy is limited 1:

• Reorientation strategies
• Environmental modifications (adequate lighting, reducing noise)
• Maintaining day-night cycles
• Early mobilization when possible
• Family presence and support

Step 3: Pharmacological Management

When pharmacological intervention is necessary:

1. Quetiapine's role:

   • May offer benefit in symptomatic management of delirium 1
   • Shows similar efficacy to haloperidol but with potentially fewer extrapyramidal side effects 2, 3
   • Appears to resolve delirium symptoms more quickly than placebo 4
   • Starting dose: 25-50mg/day, which may be titrated as needed 3

2. Alternative options:

   • Olanzapine may offer benefit (Level III, C evidence) 1
   • Aripiprazole may offer benefit (Level IV, C evidence) 1
   • Haloperidol and risperidone have no demonstrable benefit in mild-to-moderate delirium (Level I, D evidence) 1
   • Methylphenidate may improve cognition in hypoactive delirium without delusions or perceptual disturbances 1
   • Benzodiazepines for severe symptomatic distress associated with delirium 1

Special Considerations

Hyperactive Delirium

Quetiapine (25-50 mg/day) appears equally effective as haloperidol (1-2 mg/day) for hyperactive delirium, with potential benefits including:

• Reduced ICU stay (10.1 vs. 11.7 days)
• Increased sleeping hours 3

Refractory Delirium in End-of-Life Care

For refractory delirium in actively dying patients (final hours to 1-2 weeks), palliative sedation may be required, with medication levels proportionate to symptom severity 1.

Clinical Pearls and Pitfalls

• Monitoring: Regularly assess response using validated tools and adjust treatment accordingly
• Duration: The most recent evidence suggests quetiapine may need to be used for a median of 7.5 days compared to 3 days for haloperidol 5
• Dose adjustment: Quetiapine often requires dose increases from initiation to maintenance (median increase from 50mg to higher maintenance doses) 5
• QTc monitoring: Monitor for QTc prolongation, though recent evidence suggests no significant difference in QTc intervals between quetiapine and other antipsychotics 5
• Family support: Provide educational and psychological support to families when delirium develops 1

Interprofessional Considerations

Interprofessional delirium education interventions should be a core component of hospital-wide strategies to improve delirium recognition, assessment, and management 1. This includes ensuring all team members can identify early signs of delirium and implement appropriate interventions.