What medications are used to manage delirium?

Medications for Delirium Management

For patients with delirium, second-generation antipsychotics (olanzapine, quetiapine, or aripiprazole) should be used when pharmacological intervention is necessary, as these medications offer benefit in symptomatic management with fewer extrapyramidal side effects compared to first-generation antipsychotics like haloperidol. 1

Non-Pharmacological Approaches First

Before initiating medication:

• Identify and treat underlying causes of delirium
• Implement multicomponent interventions including:
  • Reorientation strategies and cognitive stimulation
  • Sleep optimization (minimizing light and noise)
  • Early mobilization and rehabilitation
  • Ensuring patients have access to hearing aids and glasses if needed
  • Reducing sedative medications when possible

These non-pharmacological approaches should be the foundation of delirium management, as they can significantly reduce delirium incidence and duration 1.

Pharmacological Management Algorithm

Step 1: Determine if medication is necessary

Medications should be limited to patients with:

• Distressing delirium symptoms (hallucinations, delusions)
• Safety concerns where the patient poses risk to self or others 1

Step 2: Select appropriate medication based on delirium subtype

For symptomatic management of delirium:

• Olanzapine: Available in oral and parenteral formulations

  • Advantages: Sedating properties beneficial for hyperactive delirium
  • Evidence level: III, C 1

• Quetiapine: Available in oral formulations only

  • Advantages: Sedating properties, fewer extrapyramidal effects
  • Evidence level: V, C 1

• Aripiprazole: Available in oral and parenteral formulations

  • Evidence level: IV, C 1

For specific delirium presentations:

• Hypoactive delirium without delusions/hallucinations: Consider methylphenidate to improve cognition 1

• Severe agitation/distress: Benzodiazepines (midazolam, lorazepam) can provide sedation and anxiolysis

  • Note: Only use after assessment of patient distress level and safety risks
  • Evidence level: II, C 1
  • Caution: Benzodiazepines can worsen delirium and increase fall risk except in alcohol/benzodiazepine withdrawal 1

Step 3: Medications to avoid or use with caution

• Haloperidol and risperidone: Not recommended for mild-to-moderate delirium as they show no demonstrable benefit and may worsen symptoms 1

• Benzodiazepines: Should not be used as initial treatment except for alcohol or benzodiazepine withdrawal 1

Special Considerations

Opioid-Associated Delirium

For patients with delirium related to opioid use:

• Reduce opioid dose or switch to a different opioid (fentanyl or methadone)
• When switching, reduce equianalgesic dose by 30-50% 1

ICU Delirium

In mechanically ventilated ICU patients:

• Dexmedetomidine may be considered when agitation is preventing weaning/extubation 1
• Multicomponent non-pharmacological interventions (ABCDEF bundle) can reduce delirium duration and mortality 1

End-of-Life Delirium

For patients with advanced cancer and limited life expectancy:

• Focus on symptom management and family support
• Consider increasing dose or changing route of administration for neuroleptics/benzodiazepines to ensure adequate symptom control
• Remove unnecessary medications and tubes 1

Dosing Considerations

All medications should be:

• Started at the lowest effective dose
• Used for the shortest time possible
• Titrated based on response
• Discontinued immediately when symptoms resolve 1

Monitoring and Follow-up

Monitor for:

• Response to treatment using standardized delirium assessment tools
• Side effects, particularly extrapyramidal symptoms with antipsychotics
• Changes in delirium presentation (fluctuations are common)

Remember that delirium causes significant distress to patients (even those with hypoactive delirium) and families. Providing information about delirium and offering debriefing opportunities after resolution are important aspects of comprehensive care 1.