What can be given to an older patient with acute confusional state (delirium)?

From the Guidelines

For an older patient with delirium, non-pharmacological approaches should be the first line of treatment, focusing on maintaining a calm environment, ensuring adequate lighting, providing orientation cues, and addressing underlying causes such as infection, dehydration, or medication side effects. This approach is supported by the National Institute for Health and Clinical Excellence guideline for prevention of delirium 1. If medications are necessary, low-dose haloperidol (0.5-1mg orally or intramuscularly) is often used for severe agitation, though antipsychotics carry risks in elderly patients, as noted in the ESMO clinical practice guidelines for delirium in adult cancer patients 1. Alternatives include quetiapine (25mg) or risperidone (0.25-0.5mg), which should be used at the lowest effective dose for the shortest duration possible. Key considerations include:

• Avoiding benzodiazepines except in alcohol withdrawal delirium, as they can worsen confusion
• Considering melatonin (2-5mg) for sleep-wake cycle disturbances
• Regular reassessment to identify and treat the root cause of delirium while providing supportive care and minimizing pharmacological interventions that could potentially worsen cognitive function in elderly patients. The most recent and highest quality study, from 2018, provides guidance on pharmacological interventions for delirium symptoms in adult patients 1.

From the FDA Drug Label

Haloperidol injection should be administered cautiously to patients: with severe cardiovascular disorders, because of the possibility of transient hypotension and/or precipitation of anginal pain Haloperidol may impair the antiparkinson effects of levodopa and other dopamine agonists. As with other antipsychotic agents, it should be noted that haloperidol may be capable of potentiating CNS depressants such as anesthetics, opioids, and alcohol.

For an older patient with delirium, haloperidol can be considered, but it should be used with caution due to the potential for:

• Transient hypotension and/or precipitation of anginal pain
• Extrapyramidal symptoms if discontinued abruptly
• Interaction with other medications, such as CNS depressants, anticonvulsants, and anticoagulants It is essential to monitor the patient closely for any adverse effects and adjust the treatment plan accordingly 2.

From the Research

Treatment Options for Delirium in Older Patients

• Haloperidol can be used off-label for agitation and/or delirium in older individuals, with a recommended initial intramuscular or intravenous dose of 0.5 to 1 mg 3
• Low-dose haloperidol (≤0.5 mg) may be similar in effect to higher doses, with fewer adverse events and better outcomes, such as reduced length of stay and utilization of restraints 3
• Benzodiazepines and neuroleptics, such as lorazepam and haloperidol, may be used to manage delirium, but their use should be limited to critical situations and the duration of medication should be limited in time 4
• Atypical antipsychotics, such as risperidone, olanzapine, and quetiapine, may be equally efficacious and safe as haloperidol in the treatment of delirium, but age should be considered when making a choice of antipsychotic medication 5, 6, 7

Comparison of Antipsychotic Medications

• Haloperidol, risperidone, olanzapine, and quetiapine were found to be equally effective in decreasing the severity and duration of delirium, with no significant differences in adverse event profiles 5, 6, 7
• Aripiprazole may also be effective in the management of delirium, with a similar side-effect profile to other atypical antipsychotics 7
• High-dose haloperidol (> 4.5 mg per day) may be associated with an increased incidence of extrapyramidal adverse effects, compared to atypical antipsychotics 6

Considerations for Treatment

• The treatment of delirium should focus on identifying and addressing underlying causes, rather than just managing symptoms with medication 4
• Non-pharmacological interventions, such as environmental modifications and behavioral therapy, should be considered before initiating medication 4
• The choice of antipsychotic medication should be individualized, taking into account the patient's age, medical history, and potential side effects 5, 6, 7