Should a patient with delirium, agitation, and a history of seizures undergo psych consult, receive sedation, and be considered for long-term seizure treatment with antiepileptic medications like levetiracetam?

Management of Delirium, Agitation, and Seizures in This Patient

Psychiatric consultation is strongly recommended for this patient presenting with delirium and agitation, particularly given the history of seizures and the complexity of managing alcohol withdrawal syndrome (AWS). 1

Psychiatric Consultation

Yes, obtain psychiatric consultation. The Korean Association for the Study of the Liver explicitly recommends psychiatric consultation for evaluation, acute management of AWS, and long-term abstinence planning, particularly when serious complications like delirium or seizures are present. 1 This consultation should guide both immediate symptom management and long-term treatment planning.

Sedation Management

Initial Approach to Agitation

Do NOT use benzodiazepines as initial treatment for delirium unless this is alcohol or benzodiazepine withdrawal. 1 Benzodiazepines can paradoxically worsen delirium and should be avoided in patients not already taking them. 1

Pharmacologic Management Algorithm

For moderate delirium with agitation:

• Start with antipsychotic medications: haloperidol, risperidone, olanzapine, or quetiapine orally 1
• These address the underlying delirium while managing agitation

For severe delirium with significant agitation:

• Use neuroleptic drugs such as haloperidol, olanzapine, or chlorpromazine 1
• IV chlorpromazine should only be used in bed-bound patients due to hypotensive effects 1
• Starting doses: haloperidol 0.5-5 mg PO/IM every 8-12 hours 1

For refractory agitation despite adequate neuroleptic dosing:

• Add a benzodiazepine (lorazepam 1-4 mg every 4-8 hours) ONLY after therapeutic neuroleptic levels are achieved 1
• The presence of therapeutic neuroleptic levels prevents paradoxical excitation from benzodiazepines 1

Critical Caveat for Alcohol Withdrawal

If this delirium is specifically alcohol withdrawal delirium (delirium tremens):

• Benzodiazepines ARE the treatment of choice 1
• Use long-acting benzodiazepines (chlordiazepoxide, diazepam) for seizure prevention 1
• Lorazepam 6-12 mg/day is preferred for patients with liver failure, respiratory failure, or serious medical comorbidities 1
• Inpatient treatment is mandatory for AWS with delirium or seizures 1

Long-Term Seizure Treatment

Decision Framework

Long-term antiepileptic therapy should NOT be routinely initiated based solely on this presentation. Here's the algorithmic approach:

Consider withholding long-term seizure prophylaxis if:

• The seizures were isolated events related to acute alcohol withdrawal 1
• The patient had a clean MRI several months prior to admission
• No evidence of structural brain lesion or ongoing seizure disorder
• Benzodiazepines during AWS treatment provide adequate seizure prophylaxis 1

Consider long-term antiepileptic therapy if:

• Seizures occurred independent of withdrawal timing
• Multiple unprovoked seizures documented
• New structural abnormalities on repeat imaging
• Neurology consultation recommends it based on seizure characteristics

Important Consideration Regarding Levetiracetam

Be cautious with levetiracetam in this specific patient. The FDA label indicates that levetiracetam itself causes behavioral symptoms (aggression, agitation, anxiety, depression, irritability) in 37.6% of pediatric patients and 13.3% of adult patients. 2 Additionally, levetiracetam can cause delirium, though this is not widely recognized. 3 Using levetiracetam in a patient already experiencing delirium and agitation could significantly worsen their psychiatric symptoms and confound the clinical picture.

If seizure prophylaxis is deemed necessary:

• Carbamazepine 200 mg every 6-8 hours is an alternative that provides seizure prevention without the behavioral side effects 1
• Phenobarbital has anticonvulsant properties and can be used for sedation if needed 1

Thiamine Administration

Administer thiamine 100-300 mg/day immediately and continue for 2-3 months to all patients with alcohol use disorder to prevent Wernicke encephalopathy. 1 Give thiamine BEFORE any IV fluids containing glucose. 1

Key Clinical Pitfalls

1. Do not assume all agitation requires sedation - identify and treat reversible causes of delirium first (infection, metabolic abnormalities, medications) 1, 4

2. Do not use benzodiazepines alone for non-withdrawal delirium - this can worsen confusion and lead to paradoxical agitation 1

3. Do not continue antipsychotics long-term - these should be discontinued immediately following resolution of distressful symptoms 1

4. Do not overlook hypoactive delirium - this subtype is often underdiagnosed and should not be treated with antipsychotics 1