What is the management plan for an 80-year-old lady presenting with paranoid accusations and suspicious behavior, diagnosed with delirium by the Mental Health Liaison Team (MHLT), despite exhibiting symptoms suggestive of paranoid behavior?

From the Guidelines

For an 87-year-old lady presenting with paranoid accusations and suspicion of staff, I recommend a comprehensive delirium management approach, prioritizing non-pharmacological interventions and using pharmacological management only when necessary. The most recent and highest quality study, 1, published in 2022, suggests that the evaluation of delirium should be done using standardized assessment tools validated in critically ill patients. Key aspects of management include:

• Conducting a thorough medical workup to identify underlying causes
• Implementing non-pharmacological interventions such as reorientation strategies, ensuring adequate hydration, maintaining a consistent care team, optimizing sensory input, and establishing a regular sleep-wake cycle
• Considering low-dose antipsychotics such as haloperidol 0.5-1 mg orally at night and every 2 hours when required, as recommended by 1, for severe agitation or distress
• Avoiding benzodiazepines unless alcohol withdrawal is suspected, as they can exacerbate delirium
• Regular reassessment to monitor for improvement or worsening of symptoms, and adjusting the management plan accordingly This approach is supported by other studies, including 1, 1, 1, and 1, which emphasize the importance of a comprehensive and multidisciplinary approach to managing delirium in elderly patients. By prioritizing non-pharmacological interventions and using pharmacological management judiciously, we can minimize the risk of adverse effects and improve outcomes for patients with delirium. It is essential to note that delirium is a common and serious condition in elderly patients, and its management requires a tailored and individualized approach, taking into account the patient's unique needs and circumstances.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management Plan for Delirium

The patient's symptoms of paranoid accusations and suspiciousness of staff may be indicative of delirium, despite initial impressions of paranoid behavior. The following management plan is based on the available evidence:

• Assessment: A comprehensive assessment of the patient's condition, including cognitive function, medical history, and current medications, is essential to determine the underlying cause of delirium 2, 3, 4, 5, 6.
• Pharmacological Interventions: The use of antipsychotic medications, such as haloperidol, risperidone, olanzapine, and quetiapine, may be effective in managing delirium 2, 3, 4, 5, 6. However, the choice of medication should be based on the patient's individual needs, medical history, and potential side effects.
• Non-Pharmacological Interventions: Non-pharmacological interventions, such as environmental modifications, cognitive stimulation, and emotional support, may also be beneficial in managing delirium 2, 3, 4, 5, 6.
• Monitoring and Evaluation: Regular monitoring and evaluation of the patient's condition, including cognitive function, medical status, and medication side effects, are crucial to ensure effective management of delirium 2, 3, 4, 5, 6.

Key Considerations

• Age: The patient's age should be considered when selecting an antipsychotic medication, as older adults may be more susceptible to side effects 6.
• Medical History: The patient's medical history, including any pre-existing conditions or medications, should be taken into account when selecting an antipsychotic medication 2, 3, 4, 5, 6.
• Side Effects: The potential side effects of antipsychotic medications, including extrapyramidal symptoms and sedation, should be carefully monitored and managed 2, 3, 4, 5, 6.

Medication Options

• Haloperidol: Haloperidol may be effective in managing delirium, but its use should be carefully considered due to the potential for extrapyramidal side effects 2, 3, 4, 5, 6.
• Risperidone: Risperidone may be a suitable alternative to haloperidol, with a lower risk of extrapyramidal side effects 2, 3, 4, 5, 6.
• Olanzapine: Olanzapine may be effective in managing delirium, but its use should be carefully considered due to the potential for sedation and other side effects 2, 3, 4, 5, 6.
• Quetiapine: Quetiapine may be a suitable alternative to other antipsychotic medications, with a lower risk of extrapyramidal side effects 2, 3, 4, 5, 6.