From the Guidelines
Hypoactive delirium should be managed by identifying and addressing underlying causes, utilizing non-pharmacological approaches as the cornerstone of treatment, and reserving pharmacological interventions for severe symptoms, with haloperidol being the preferred agent due to its efficacy and relatively favorable side effect profile, as supported by the most recent guidelines 1.
Introduction to Hypoactive Delirium
Hypoactive delirium is characterized by reduced alertness, decreased motor activity, and lethargy, often making it overlooked in clinical settings. It is a subtype of delirium that presents with subdued behavior, in contrast to hyperactive delirium, which is marked by agitation and increased motor activity.
Diagnosis and Assessment
Diagnosis should be done using standardized assessment tools validated in critically ill patients, such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or Intensive Care Delirium Screening Checklist (ICDSC), as recommended by recent guidelines 1. Identifying reversible causes, such as drug-induced delirium, metabolic disturbances, or poorly controlled pain, is crucial.
Treatment Approaches
Treatment begins with addressing underlying causes and optimizing pain control before considering pharmacological interventions. Non-pharmacological approaches are fundamental and include:
- Maintaining a consistent sleep-wake cycle
- Frequent reorientation
- Ensuring adequate hydration and nutrition
- Early mobilization
- Creating a calm environment with familiar objects
Pharmacological Interventions
Pharmacological interventions should be used cautiously and only when necessary. For severe symptoms, low-dose antipsychotics may be considered:
- Haloperidol (0.5-1mg orally or IV) is preferred due to its efficacy and relatively favorable side effect profile, as supported by recent evidence 1.
- Atypical antipsychotics such as quetiapine (25-50mg) or risperidone (0.5-1mg) may also be used, but with careful consideration of their side effect profiles.
Considerations and Prognosis
Benzodiazepines are generally avoided except in alcohol withdrawal cases due to their potential to worsen delirium. Close monitoring for medication side effects is essential. Family involvement in care can significantly improve outcomes by providing familiar faces and voices. The prognosis for hypoactive delirium is generally good when underlying causes are promptly identified and addressed, though elderly patients may experience longer recovery periods and increased risk of complications.
From the Research
Cases of Hypoactive Delirium
- Hypoactive delirium is common among older hospitalized patients, with a prevalence of 29-64% of all older patients in hospital developing a delirium, of which the majority is of the hypoactive subtype 2
- Hypoactive delirium often remains undiagnosed or is only diagnosed late, and prognosis is worse than for hyperactive delirium 2
- The mixed subtype of delirium caused more severe and persistent delirium, and the hypoactive subtype was more persistent than the hyperactive subtype 3
Treatment Options for Hypoactive Delirium
- Aripiprazole and methylphenidate showed promising results in the treatment of hypoactive delirium, with aripiprazole showing a complete resolution of hypoactive delirium (P < .001) and methylphenidate showing a significant amelioration in cognitive function (P < .001) 4
- Ziprasidone and haloperidol did not show significant differences compared with placebo in the treatment of hypoactive delirium 4
- Antipsychotics should only be considered after all non-pharmacological options have been tried, no obvious and solvable cause for the delirium has been found, and the patient is visibly suffering from the psychotic symptoms 2
- Non-pharmacological approaches to prevention and treatment of delirium are the most effective, with multi-component non-pharmacological approaches showing the most benefit 5
- Antipsychotics may be used to treat agitation, psychosis, and distress associated with delirium at the lowest effective doses and shortest possible duration, but should not be considered a treatment of delirium itself 5