What is the management of delirium in patients undergoing dialysis?

Management of Delirium in Dialysis Patients

Delirium in dialysis patients requires immediate identification and treatment of underlying causes, with non-pharmacological interventions as first-line therapy, followed by cautious use of haloperidol for severe hyperactive symptoms when necessary, while recognizing that dialysis patients may require higher doses than previously assumed due to altered pharmacokinetics. 1, 2

Immediate Assessment and Recognition

Screen for Dialysis-Specific Causes of Delirium

• Rule out aluminum neurotoxicity first in any dialysis patient presenting with delirium, as this represents a potentially reversible but life-threatening cause 1

  • Check plasma aluminum levels (normal <10 µg/L; toxicity suspected >100 µg/L; acute toxicity >400 µg/L) 1
  • Acute aluminum neurotoxicity presents with agitation, confusion, myoclonic jerks, and seizures—this is a medical emergency 1
  • Dialysis encephalopathy presents more insidiously after 12-24 months of dialysis with speech disturbances (stuttering, stammering), personality changes, motor disturbances, and hallucinations 1, 3
  • Obtain EEG showing characteristic patterns distinct from other metabolic encephalopathies 1, 3

• Assess for metabolic derangements common in dialysis patients 1, 4

  • Evaluate blood urea nitrogen/creatinine ratio (elevated ratios increase delirium risk) 4
  • Check for hypoxia, hypoglycemia, electrolyte imbalances, and uremia 1, 4
  • Assess hydration status and correct dehydration 1, 4

• Use validated screening tools to detect delirium, as it frequently goes unrecognized without systematic assessment 1

  • Implement CAM-ICU (Confusion Assessment Method-ICU) or ICDSC (Intensive Care Delirium Screening Checklist) 1
  • Screen for both hyperactive and hypoactive delirium subtypes, as hypoactive delirium is commonly missed and may have worse outcomes 1

Identify Precipitating Factors

• Review and minimize deliriogenic medications, particularly benzodiazepines, which are strongly associated with delirium development 1
• Assess for infection, pain, and acute illness as common precipitating factors in this vulnerable population 1
• Evaluate psychological factors including depression and anxiety, which are highly prevalent (25-50% depression rates, 45% anxiety rates) in dialysis patients and may contribute to delirium 1, 5

Non-Pharmacological Management (First-Line)

Environmental and Supportive Interventions

• Implement multicomponent non-pharmacological strategies before considering medications, as these reduce delirium duration, ICU length of stay, and mortality 1, 6

  • Create a calm, quiet environment that promotes orientation 1, 6
  • Display visible calendars and clocks 6
  • Maintain caregiver consistency 6
  • Provide repeated reorientation to person, place, and time 4
  • Optimize lighting and reduce unnecessary noise 7, 4

• Promote good sleep hygiene as sleep alterations are a modifiable risk factor for delirium 1, 4

• Encourage early mobilization when medically appropriate 1, 4

• Implement fall prevention measures given increased risk in delirious patients 1

Address Sensory Deficits

• Correct visual and hearing impairments, as these increase delirium risk 7, 4
• Ensure patients have access to glasses and hearing aids if normally used 7

Pharmacological Management (When Non-Pharmacological Measures Insufficient)

Haloperidol for Hyperactive Delirium

• Use haloperidol cautiously for severe hyperactive delirium with significant agitation, hallucinations, or delusions that cause distress and do not respond to non-pharmacological interventions 1, 6

  • Initial dosing: 0.5-2 mg IV slow bolus 6
  • Critical caveat: Dialysis patients require HIGHER doses than previously assumed (12-24 mg daily may be needed for symptom control) due to altered pharmacokinetics 2
  • Blood concentrations of haloperidol are significantly higher in dialysis patients, with only approximately 25% clearance during dialysis 2
  • Monitor closely for efficacy and side effects given unpredictable pharmacokinetics 2

• Discontinue antipsychotics immediately once distressful symptoms resolve, as they do not shorten delirium duration or improve mortality 6

• Avoid routine use of haloperidol or atypical antipsychotics for hypoactive delirium or non-agitated states 1, 6, 7

Medications to Avoid

• Do NOT use benzodiazepines for delirium management in dialysis patients (except for alcohol/drug withdrawal delirium tremens) 6, 7
  • Benzodiazepines increase delirium risk, prolong delirium duration, and significantly increase fall risk 7
  • They are strongly associated with delirium development in vulnerable populations 1

Alternative Sedation if Needed

• Consider dexmedetomidine when agitation precludes weaning from mechanical ventilation or for hyperactive delirium resolution in intubated patients 1, 6
  • Dexmedetomidine may be associated with improved delirium outcomes compared to benzodiazepines 1

Special Considerations for Dialysis Patients

Aluminum-Related Delirium Treatment

• If aluminum toxicity confirmed, stop all aluminum-containing medications (aluminum-based phosphate binders) 1
• Ensure water purification systems are functioning to prevent dialysate aluminum contamination 1, 3
• Consider deferoxamine (DFO) therapy for severe aluminum overload, but use cautiously as it can precipitate acute neurotoxicity if given too rapidly (start with lower doses <20 mg/kg) 1

Palliative Care Considerations

• Discuss goals of care with patients who have severely limited life expectancy, low quality of life, or progressive deterioration 1
• Consider conservative management as an alternative to continued dialysis in appropriate cases through shared decision-making 1
• Provide integrated palliative care for symptom control (fatigue, dyspnea, anxiety, pruritus) if dialysis is discontinued 1

Critical Pitfalls to Avoid

• Do not dismiss delirium as "expected" in dialysis patients—it requires thorough evaluation for treatable causes 1, 5
• Do not overlook hypoactive delirium, which is easily missed but may have worse outcomes 1
• Do not use standard dosing assumptions for haloperidol—dialysis patients have altered pharmacokinetics requiring individualized dosing 2
• Do not forget to obtain EEG in patients with suspected hypoactive delirium to rule out non-convulsive status epilepticus, which is treatable 1
• Do not attribute all symptoms to uremia or "dialysis dementia" without considering aluminum toxicity, especially in long-term dialysis patients 1, 3
• Do not combine multiple sedating medications except in crisis situations 7