What is the first-line medication for agitation secondary to delirium?

First-Line Medication for Agitation Secondary to Delirium

For agitation secondary to delirium, non-pharmacological interventions should be implemented first, with haloperidol as the first-line pharmacological agent when medication is necessary for severe symptoms that pose safety risks.

Non-Pharmacological Interventions First

Before considering medications, implement these non-pharmacological strategies:

• Reorientation strategies (orientation boards, visible clocks)
• Environmental modifications (reduce noise, maintain consistent care teams)
• Sensory support (ensure eyeglasses and hearing aids are available)
• Early mobilization
• Sleep-wake cycle regulation
• Family involvement 1

Pharmacological Management Algorithm

First-Line Agent:

• Haloperidol (typical antipsychotic)
  • Starting dose: 0.5-1 mg IV/IM 1, 2, 3
  • Low doses (≤0.5 mg) have shown similar efficacy to higher doses with fewer side effects 3
  • Can be titrated based on response
  • Monitor for QT prolongation and extrapyramidal symptoms

Second-Line Agents:

• Atypical antipsychotics (if haloperidol is contraindicated or ineffective):
  • Quetiapine
  • Olanzapine
  • Risperidone 4, 1

Special Circumstances:

• For mechanically ventilated patients where agitation precludes weaning/extubation:
  • Consider dexmedetomidine 4
  • Shown to increase ventilator-free hours and faster resolution of delirium symptoms 4

Important Considerations

• Medications should only be used when non-pharmacological measures are insufficient and the patient presents severe symptoms that pose a risk to safety 1
• Avoid benzodiazepines except in cases of alcohol or sedative-hypnotic withdrawal 5
• Discontinue antipsychotics immediately following resolution of distressing symptoms 4
• Current guidelines suggest against routine use of antipsychotics for delirium treatment 4
• Patients who start antipsychotics in the ICU often remain on these medications unnecessarily after discharge 4

Monitoring and Follow-up

• Regularly reassess using validated tools (CAM, CAM-ICU, RASS)
• Monitor for side effects:
  • Extrapyramidal symptoms
  • QT prolongation
  • Excessive sedation
• Adjust dosing based on response and side effects
• Discontinue as soon as agitation resolves

Cautions

• Higher doses of haloperidol are associated with increased risk of sedation without improved efficacy 2, 3
• Antipsychotics carry a black box warning for increased mortality in elderly patients with dementia-related psychosis 6
• Continuous haloperidol infusions should only be considered in cases of severe, refractory agitation with close cardiac monitoring 7, 8

Remember that the underlying cause of delirium must be identified and treated simultaneously with symptom management for best outcomes.