What medications are used to manage delirium-induced agitation?

Management of Delirium-Induced Agitation

Non-pharmacological interventions should be implemented first for all patients with delirium-induced agitation, with pharmacological management reserved for patients with significant distress from hallucinations/delusions or severe agitation that poses risk to themselves or others. 1

First-Line Approach: Non-Pharmacological Interventions

• Implement multicomponent interventions including reorientation, cognitive stimulation, use of clocks and calendars, optimizing sleep, reducing unnecessary sedation, early mobilization, and ensuring access to hearing aids and glasses if needed 1, 2
• Provide ongoing educational programs for healthcare professionals regarding delirium management 2
• Identify and manage underlying medical contributors to delirium through comprehensive evaluation 1, 2
• Optimize pain management, preferably with non-opioid medications, to prevent worsening delirium 2
• Avoid medications with high risk for precipitating or worsening delirium 2

Pharmacological Management for Severe Agitation

When non-pharmacological approaches are insufficient for managing severe agitation:

Antipsychotics

• Antipsychotics should not be used routinely but may be considered for short-term use in patients with significant distress or severe agitation 2, 1
• Use the lowest effective dose for the shortest possible duration 2, 1
• Options include:
  • Haloperidol: 0.5-2 mg PO/IV/IM (reduce dose in older adults) 2, 3
  • Olanzapine: 2.5-5 mg PO/IM (sedating effect may be beneficial in hyperactive delirium) 2
  • Quetiapine: 25-50 mg PO (less likely to cause extrapyramidal symptoms) 2
  • Risperidone: 0.5 mg PO (available as orally disintegrating tablet) 2
  • Aripiprazole: 5 mg PO/IM (less likely to cause extrapyramidal symptoms) 2

Special Situations

• Dexmedetomidine is recommended for mechanically ventilated patients with agitation preventing weaning/extubation 2, 4
• For alcohol or benzodiazepine withdrawal-induced delirium, benzodiazepines are the treatment of choice 2

Benzodiazepines

• Benzodiazepines should not be used as first-line treatment of agitation associated with delirium 2, 1
• May be considered as crisis medication for severe agitation when other approaches fail 2
• Options in severe cases:
  • Midazolam: 0.5-2.5 mg SC/IV (lower doses in older/frail patients) 2
  • Lorazepam: 0.25-1 mg SC/IV/PO (can cause paradoxical agitation) 2

Important Clinical Considerations

• Discontinue all antipsychotic agents immediately following resolution of distressing symptoms 2, 1
• Monitor for adverse effects of antipsychotics, particularly extrapyramidal symptoms with higher doses of haloperidol 5, 3
• Low-dose haloperidol appears to be as effective as and safer than higher doses in older adults 3
• Antipsychotics and benzodiazepines should be avoided for treatment of hypoactive delirium 2
• Cholinesterase inhibitors should not be newly prescribed to prevent or treat postoperative delirium 2
• Atypical antipsychotics (olanzapine, risperidone, quetiapine) may have similar efficacy to haloperidol with potentially fewer extrapyramidal side effects 5, 2

Monitoring and Reassessment

• Regularly assess response to interventions using validated delirium assessment tools 4
• Evaluate the need for continued medication daily 4
• Continue to address underlying causes of delirium while managing symptoms 1
• Monitor for sedation, which increases with higher doses of antipsychotics 3