What medications are used to treat delirium?

Medications for the Treatment of Delirium

Antipsychotics should not be routinely used as first-line treatment for delirium, but non-pharmacological multicomponent interventions should be prioritized instead. 1

Non-Pharmacological Management (First-Line)

The cornerstone of delirium management is non-pharmacological intervention, which should be implemented before considering medications:

• Multicomponent interventions that focus on:

  • Reorientation strategies (clocks, calendars, familiar objects)
  • Cognitive stimulation
  • Sleep optimization (minimizing noise and light at night)
  • Reduced sedation when possible
  • Early rehabilitation and mobilization
  • Addressing sensory impairments (providing glasses, hearing aids) 1, 2

• ABCDEF Bundle implementation:

  • A: Assessment and management of pain
  • B: Both spontaneous awakening and breathing trials
  • C: Choice of appropriate sedation
  • D: Delirium monitoring and management
  • E: Early mobility
  • F: Family engagement 1, 2

Pharmacological Management

When medications are necessary (primarily for severe agitation or distress):

Recommended Medications:

1. Atypical Antipsychotics (preferred over typical antipsychotics):

   • Olanzapine: 2.5-5 mg PO/SC [III, C] 1
   • Quetiapine: 25 mg immediate release [V, C] 1, 3
   • Aripiprazole: 5 mg PO/IM [IV, C] 1

2. For Specific Situations:

   • Dexmedetomidine: For mechanically ventilated patients where agitation is preventing weaning/extubation 1
   • Benzodiazepines: Only for alcohol or benzodiazepine withdrawal delirium 1, 2

Medications to Avoid or Use with Caution:

1. Haloperidol and Risperidone: Not recommended for mild-to-moderate delirium as they may worsen symptoms [I, D] 1

2. Statins: Not recommended for delirium treatment 1

Clinical Decision Algorithm

1. Confirm delirium diagnosis using validated tools (CAM, CAM-ICU)

2. Identify and treat underlying causes:

   • Infection
   • Metabolic disturbances
   • Medication effects
   • Pain
   • Hypoxemia
   • Withdrawal syndromes

3. Implement non-pharmacological interventions (as detailed above)

4. Consider pharmacological treatment only if:

   • Patient has significant distress from hallucinations or delusions
   • Agitation poses safety risk to patient or others
   • Non-pharmacological interventions have failed 1

5. Medication selection based on presentation:

   • Severe agitation with safety concerns: Short-term atypical antipsychotic
   • Mechanically ventilated with agitation preventing extubation: Dexmedetomidine
   • Alcohol/benzodiazepine withdrawal delirium: Benzodiazepines

Important Considerations

• Short-term use only: Discontinue antipsychotics immediately following resolution of distressing symptoms 1

• Monitoring: Regular assessment of response and side effects

• Dosing: Start with low doses in elderly or frail patients

• Common pitfalls:

  • Underrecognition of hypoactive delirium
  • Overreliance on medications
  • Failure to address reversible causes
  • Inadequate non-pharmacological interventions 2

The evidence supporting pharmacological management of delirium is limited, with most studies showing no significant benefit in reducing delirium duration, ICU length of stay, or mortality 1. Therefore, the focus should remain on prevention, early identification, and non-pharmacological management whenever possible.