How to manage a patient with delirium and semi-purposeful movements?

Management of Delirium with Semi-Purposeful Movements

For patients with delirium exhibiting semi-purposeful movements, a multicomponent intervention approach should be implemented first, with pharmacological management reserved for distressing symptoms or safety concerns, using olanzapine, quetiapine, or aripiprazole at the lowest effective dose for the shortest duration possible. 1

Initial Assessment and Non-Pharmacological Management

Identify and Address Underlying Causes

• Search for potentially reversible causes:
  • Infections (treat if consistent with goals of care) 1
  • Medication effects (consider discontinuation of implicated medications) 1
  • Metabolic disturbances (correct electrolyte abnormalities) 1
  • Hypoxia (optimize oxygen saturation) 1
  • Dehydration (ensure adequate fluid intake) 1

Environmental Interventions

1. Maintain continuity of care:

   • Avoid moving patients between rooms or wards unless absolutely necessary 1
   • Ensure care is provided by consistent healthcare professionals 1

2. Reorientation strategies:

   • Provide appropriate lighting and clear signage 1
   • Ensure clocks and calendars are easily visible 1
   • Regularly reorient the patient by explaining where they are and who you are 1
   • Facilitate regular visits from family and friends 1

3. Optimize sensory input:

   • Ensure patients have access to eyeglasses, hearing aids if needed 2
   • Reduce unnecessary noise and stimuli, especially at night 1

4. Promote normal sleep-wake cycles:

   • Control light and noise levels 1
   • Cluster patient care activities to minimize disruptions 1
   • Decrease nocturnal stimuli 1

5. Early mobilization:

   • Encourage physical activity and exercise when safe 1
   • Avoid unnecessary physical restraints which may worsen agitation 2

Pharmacological Management

Pharmacological interventions should be limited to patients with distressing symptoms (such as perceptual disturbances) or when there are safety concerns where the patient poses a risk to themselves or others 1.

First-Line Agents for Semi-Purposeful Movements:

1. Antipsychotics (for distressing symptoms or safety concerns):

   • Olanzapine: May offer benefit in symptomatic management 1

     • Available in oral, orally dispersible, and parenteral formulations
     • Sedation is a recognized side effect which may be advantageous in hyperactive delirium

   • Quetiapine: May offer benefit in symptomatic management 1

     • Available in oral formulations only
     • Sedative properties can help with agitation

   • Aripiprazole: May offer benefit in symptomatic management 1

     • Available in oral, orally dispersible, and parenteral formulations in some countries

   • These second-generation antipsychotics are less likely to cause extrapyramidal side effects than first-generation antipsychotics 1

2. For hypoactive delirium:

   • Methylphenidate may improve cognition in hypoactive delirium where delusions or perceptual disturbances are absent 1

Crisis Intervention for Severe Agitation:

Benzodiazepines:

• Effective for providing sedation and anxiolysis in acute management of severe symptomatic distress 1
• Should not be used as first-line treatment except in alcohol or benzodiazepine withdrawal 2
• Options include:
  • Midazolam: 2.5 mg SC/IV q1h PRN (up to 5 mg maximum) 1
  • Lorazepam: 1 mg SC/IV stat (up to 2 mg maximum) 1
• Use lower doses in older or frail patients 1

Important Considerations and Pitfalls

1. Medication cautions:

   • Use medications at the lowest effective dose for the shortest time possible 1
   • Start medications on a PRN (as needed) basis before considering scheduled dosing 1
   • Benzodiazepines can be deliriogenic and increase fall risk - use only when necessary 1
   • Antipsychotics themselves can cause increased agitation and delirium 1

2. Common pitfalls to avoid:

   • Misdiagnosing hypoactive delirium as dementia 2
   • Failing to recognize delirium superimposed on dementia 2
   • Overmedicating without addressing underlying causes 2
   • Using benzodiazepines as first-line treatment (except in alcohol/benzodiazepine withdrawal) 1, 2

3. Support for family and healthcare team:

   • Provide information about delirium to family members 1
   • Explain the fluctuating nature of delirium and appropriate responses 1
   • Consider debriefing sessions for healthcare team after challenging cases 1

By implementing this comprehensive approach to managing delirium with semi-purposeful movements, clinicians can effectively address both the underlying causes and distressing symptoms while minimizing risks associated with pharmacological interventions.