Delirium with perceptual disturbances

F05.0-1/F05.8-9/R45.1/R45.4-6

DESCRIPTION

Confusional states/delirium are characterised by altered consciousness, accompanied by impairments in orientation to time and place and seldom to person. Mental status may fluctuate. Disturbed behaviour may be present, e.g. agitation, hallucinations and paranoid ideation.

Note: Many acute medical emergencies can present as delirium, which may be misdiagnosed as an acute psychosis.

GENERAL MEASURES

  • Investigations need to be done to exclude or diagnose an underlying medical problem, the treatment of which is the primary management.
  • Ensure effective communication, re-orientation and reassurance.

MEDICINE TREATMENT

Treat underlying medical condition.

Acute management

For management for severe aggression and disruptive behaviour: see Aggressive disruptive behaviour in adults.

LoEIII [18]

For agitated and acutely disturbed patient:

  • Haloperidol, IM, 0.5–1 mg
    • This can be repeated in 30–60 minutes, if required and then 4 hourly to a maximum dose of 10 mg within 24 hours.
    • Monitor vital signs and beware of acute dystonia and neuroleptic malignant syndrome.
    • Dosing may vary according to clinical circumstances, e.g. lower doses in the elderly or where HIV infection or HIV-related dementia is known or suspected.

AND/OR

  • Benzodiazepine, repeat as necessary, to achieve containment, e.g.:
  • Lorazepam, IM, 1–4 mg.

OR

  • Clonazepam, IM, 0.5–2 mg.

OR

  • Diazepam, IV, 10 mg.
    • Switch to oral route once containment is achieved.

Note:

CAUTION

Benzodiazepines, especially diazepam IV, can cause respiratory depression.

Monitor patients closely.

LoEIII [19]

  • In the frail and elderly patient or where respiratory depression is a concern, reduce the dose by half.
  • The safest route of administration is oral followed by IM with the IV route having the highest risk of respiratory depression and arrest. Use the safest route wherever possible.
  • Monitor vital signs closely during and after administration.
  • Use haloperidol instead of benzodiazepines in patients with respiratory insufficiency.
  • In the short-term, benzodiazepines can aggravate delirium.
  • To avoid inappropriate repeat dosing allow at least 15–30 minutes for the medication to take effect. Repeated IM doses of benzodiazepines may result in toxicity owing to accumulation.
  • Physical restraint worsens the outcomes of delirious patients: this is a last resort when all else has failed and is a short-term measure until chemical restraint has been achieved.