What is the recommended medication for an 87-year-old female patient with a subdural hematoma experiencing delirium?

Management of Delirium in an 87-Year-Old Female with Subdural Hematoma

For this elderly patient with subdural hematoma and delirium, prioritize non-pharmacological interventions first, and reserve antipsychotic medications (haloperidol 0.5-1 mg or quetiapine 25-50 mg) only for severe agitation that poses safety risks to the patient or staff, as routine antipsychotic use does not improve delirium outcomes and may cause harm. 1

Initial Assessment and Risk Factor Management

Before considering any medication, identify and address reversible causes through comprehensive evaluation 1:

• Screen for metabolic derangements: hypoxia, electrolyte imbalances, hypoglycemia, dehydration 1
• Evaluate for infection: urinary tract infection, pneumonia, or other sources 1
• Review all medications: discontinue or reduce anticholinergics, benzodiazepines, steroids, and opioids that may be contributing 1
• Assess for increased intracranial pressure: particularly relevant given the subdural hematoma, as this may require neurosurgical intervention 2, 3
• Check for urinary retention or constipation: both common precipitants in elderly patients 1

The subdural hematoma itself is a critical consideration, as it represents a potentially reversible structural cause of delirium that may require surgical evacuation 2, 3.

Non-Pharmacological Interventions (First-Line)

Implement multicomponent non-pharmacological strategies as the primary treatment approach, as these have demonstrated reduced delirium duration, ICU length of stay, and mortality without adverse effects 1:

• Reorientation strategies: use clocks, calendars, and familiar objects; ensure family presence 1
• Optimize sensory function: provide hearing aids and eyeglasses if normally used 1
• Promote sleep hygiene: minimize nighttime noise and light, cluster care activities 1
• Early mobilization: encourage out-of-bed activity as tolerated given the subdural hematoma 1
• Maintain adequate hydration and nutrition: address dehydration if present 1
• Remove unnecessary tubes and catheters: reduce tethering devices 1

Pharmacological Management (Reserved for Specific Indications)

When NOT to Use Antipsychotics

Critical care and oncology guidelines explicitly recommend against routine antipsychotic use for mild-to-moderate delirium, as haloperidol and risperidone show no benefit in reducing delirium duration, mechanical ventilation days, ICU length of stay, or mortality 1. This represents high-quality evidence from multiple randomized controlled trials 1.

When Antipsychotics May Be Warranted

Use antipsychotics only for severe distress or safety concerns 1:

• Hallucinations or delusions causing significant fear or distress 1
• Hyperactive delirium with agitation posing risk of self-harm or harm to staff 1
• Agitation threatening interruption of essential medical therapies 4

Specific Medication Recommendations

If pharmacological intervention is necessary 1:

• Haloperidol: Start 0.5-1 mg orally or IV every 4-6 hours as needed (lower doses for elderly) 1

  • Monitor for QT prolongation and extrapyramidal side effects 1
  • Discontinue immediately once distressing symptoms resolve 1

• Quetiapine: 25-50 mg orally twice daily, may be preferable for hypoactive delirium due to sedating properties 1

  • Available only in oral formulation 1
  • Less risk of extrapyramidal side effects than haloperidol 1

• Olanzapine: 2.5-5 mg orally or IM daily, offers sedation benefit in hyperactive delirium 1

Critical Caveats

Avoid benzodiazepines as initial treatment unless the delirium is due to alcohol or benzodiazepine withdrawal 1. Benzodiazepines are deliriogenic, increase fall risk (particularly dangerous with subdural hematoma), and may worsen confusion 1. They should only be added for refractory agitation despite adequate antipsychotic dosing, and only when therapeutic neuroleptic levels are present to prevent paradoxical excitation 1.

Special Considerations for Subdural Hematoma

The presence of subdural hematoma adds complexity 2, 3:

• Delirium may indicate hematoma expansion or increased intracranial pressure requiring urgent neurosurgical evaluation 2
• Post-operative delirium is common after hematoma evacuation, occurring in up to 22.7% of cases 3
• Rapid decompression can cause hyperperfusion syndrome, further contributing to delirium 3
• Fall prevention is paramount, as additional trauma could be catastrophic 1

Monitoring and Duration

Use the lowest effective dose for the shortest duration possible 1. Antipsychotics should be discontinued immediately once the acute distressing symptoms resolve 1. Continue daily delirium assessment using validated tools and reassess the need for continued pharmacological intervention 1, 4.

Support caregivers throughout, as witnessing delirium is highly distressing for families 1. Provide education about the condition and expected course 1.