Psychiatry

76 yo woman with inpatient psych consult for depression

Carrie Tamarelli on Jan 26, 2018 - University of Michigan

Most agree on nonpharmacologic interventions and removal/replacement of deliriogenic medications as appropriate for the management of delirium. If delirium persists despite these efforts, are there any pharmacologic options that might play a role in treatment of hypoactive delirium?

Select all that apply
Expand all answers
Melatonin
Yes, as it can assist in the promotion of more natural sleep. Although sedating antidepressants (trazodone, mirtazapine) may also be used, their effects may persist beyond nighttime sleep and be sedating into the following day [1].


Haloperidol
Sometimes. Very low dose IV haloperidol is a reasonable choice for hypoactive delirium given theoretical dopamine excess as a mechanism of delirium. Haloperidol is preferred as the least sedating typical antipsychotic (risperidone among the atypicals) [1]. If used, don’t forget to monitor QTc, K, and Mg.


Lorazepam
No. Although less common in hypoactive delirium, sometimes clinicians turn to benzodiazepines to manage agitation in hyperactive or mixed type delirium. Other agents are generally more appropriate, however.


Modafinil
Maybe. For hypoactive delirium, it has been suggested in cases of profound psychomotor retardation where psychosis is not present, though there is limited evidence to support improved outcomes [1].


Vitamin D
Maybe. One case control study of patients with hip fracture found an independent association between the risk of delirium and low concentration of 25(OH) [2].


These pharmacologic interventions are more controversial, and practices often vary by institution, especially when multiple specialties (psychiatry, critical care, geriatric medicine, etc) are involved. 

[1] Maldonado JR. Delirium in the acute care setting: Characteristics, diagnosis and treatment. Crit Care Clin. 2008. 24:657-722.

[2] Torbergsen AC, et al. Vitamin deficiency as a risk factor for delirium. Euro Geri Med. 2015. 6(4)314-318.

Most agree on nonpharmacologic interventions and removal/replacement of deliriogenic medications as appropriate for the management of delirium. If delirium persists despite these efforts, are there any pharmacologic options that might play a role in treatment of hypoactive delirium?

Select all that apply
Expand all answers
Melatonin
Yes, as it can assist in the promotion of more natural sleep. Although sedating antidepressants (trazodone, mirtazapine) may also be used, their effects may persist beyond nighttime sleep and be sedating into the following day [1].


Haloperidol
Sometimes. Very low dose IV haloperidol is a reasonable choice for hypoactive delirium given theoretical dopamine excess as a mechanism of delirium. Haloperidol is preferred as the least sedating typical antipsychotic (risperidone among the atypicals) [1]. If used, don’t forget to monitor QTc, K, and Mg.


Lorazepam
No. Although less common in hypoactive delirium, sometimes clinicians turn to benzodiazepines to manage agitation in hyperactive or mixed type delirium. Other agents are generally more appropriate, however.


Modafinil
Maybe. For hypoactive delirium, it has been suggested in cases of profound psychomotor retardation where psychosis is not present, though there is limited evidence to support improved outcomes [1].


Vitamin D
Maybe. One case control study of patients with hip fracture found an independent association between the risk of delirium and low concentration of 25(OH) [2].


These pharmacologic interventions are more controversial, and practices often vary by institution, especially when multiple specialties (psychiatry, critical care, geriatric medicine, etc) are involved. 

[1] Maldonado JR. Delirium in the acute care setting: Characteristics, diagnosis and treatment. Crit Care Clin. 2008. 24:657-722.

[2] Torbergsen AC, et al. Vitamin deficiency as a risk factor for delirium. Euro Geri Med. 2015. 6(4)314-318.

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