Guideline Watch: Practice Guideline for the Treatment of  
Patients With Delirium

Ian Cook

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Guideline Watch: Practice Guideline for the Treatment of Patients With Delirium

Ian A. Cook

DOI: 10.1176/appi.books.9780890423363.147844

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References

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Introduction
Detection
Neuropathophysiologic Models

Management
References

Introduction

Since the 1999 publication of the APA's Practice Guideline for the Treatment of Patients With Delirium (1), advances in the clinical neurosciences and other areas have contributed to the understanding of delirium and have expanded options for its management. This guideline watch summarizes important elements of the incremental progress in this area.

The American Psychiatric Association (APA) practice guidelines are developed by expert work groups using an explicit methodology that includes rigorous review of available evidence, broad peer review of iterative drafts, and formal approval by the APA Assembly and Board of Trustees. APA practice guidelines are intended to assist psychiatrists in clinical decision making. They are not intended to be a standard of care. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available. Guideline watches summarize significant developments in practice since publication of an APA practice guideline. Watches may be authored and reviewed by experts associated with the original guideline development effort and are approved for publication by APA's Executive Committee on Practice Guidelines. Thus, watches represent opinion of the authors and approval of the Executive Committee but not policy of the APA. This guideline watch was published in August 2004. Copyright © 2004. American Psychiatric Association. All rights reserved. Suggested citation: Cook IA: Guideline Watch: Practice Guideline for the Treatment of Patients With Delirium. Arlington, VA: American Psychiatric Association, 2004. Available online at http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm.

Detection

The 1999 guideline noted that the presence of delirium is frequently undetected by clinicians until psychiatric consultation is obtained, often triggered by dangerous behaviors. In the years since 1999, many papers providing easily remembered strategies for clinical detection and management of delirium have been published, not only in the psychiatric literature but also in journals that focus on critical care, pain management, oncology, medical-surgical nursing, substance abuse, and geriatric medicine. Despite this broadening literature base, it has been noted that many cases of delirium continue to be missed (2). Reasons for this underrecognition are varied but may include the absence of routine, systematic screening (3). Improved attention to and recognition of delirium should be motivated by its clinical importance (e.g., association with elevated mortality [4]).

One step toward improved detection may be the use of instruments that have demonstrated sensitivity to the presence of delirium. Examples include the Delirium Rating ScaleRevised–98 (5, 6), including a version for use with children (7); the Delirium Observation Screening Scale (8); and the Confusion Assessment Method for the Intensive Care Unit (9–11). Instruments have variable concordance with the diagnostic criteria detailed in DSM-IV, and each instrument may be better suited to particular clinical contexts.

Neuropathophysiologic Models

The etiologic heterogeneity of delirium is a persistent theme in the more recent literature (10, 12–15). The role of the anticholinergic properties of a variety of medications continues to be noted (16, 17). In a patient population with a mixture of putative causes of delirium, regional cerebral perfusion was consistently reported to show significant reductions during periods of delirium in comparison with blood flow patterns after recovery (18). The possibility of a final common pathway, involving acetylcholine and dopamine, has been advanced (15, 19, 20). The feature of sleep/wake cycle disruption in delirium has led others to speculate about the possible role of melatonin (21, 22). Although more research could prove illuminating, there are practical challenges to performing controlled clinical investigations with delirious persons, thoughtfully summarized by Meagher (23). Despite these challenges, there is pressing need for more research in this area.

Management

Management of patients with delirium continues to focus on ensuring safety from behavioral disturbances while simultaneously assessing for a probable etiology and definitive treatment. Safety can best be addressed by combining environmental, behavioral, and pharmacologic means. In addition to the alterations in the hospital environment noted in the 1999 guideline, low-tech but potentially labor-intensive changes in nurse–patient interactions, as well as flexibility within hospital systems to individualize processes of care, may be able to reduce the impact of delirium (24). Behavioral programs can be highly effective but appear to be critically dependent on adherence to the details of the program (25).

Current pharmacological interventions expand the options reported in the 1999 guideline. Data supporting the use of first-generation antipsychotic medications (12) have been joined by case reports, case series, and a limited number of open-label trials supporting the use of second-generation antipsychotic medications (26) such as olanzapine (27–29), risperidone (30–32), ziprasidone (33), and quetiapine (34–38). The prophylactic use of haloperidol has been examined in hip surgery patients in a prospective, double-blind, placebo-controlled trial (39), and although the incidence of delirium was not significantly altered by the intervention, there were significant differences in important secondary measures (duration of delirium, length of stay, Delirium Rating Scale scores) in this prevention trial. Given the dearth of research data, there is a clear need for prospective, randomized, controlled efficacy trials of second-generation antipsychotic medications for the management of delirium. Cholinesterase inhibitors also have shown success in managing delirium in some case reports, but usually for reversing drug-induced delirium, both for donepezil (40–43) and rivastigmine (44). The avoidance of benzodiazepines except for particular indications (e.g., alcohol or -hydroxybutyric acid [GHA] withdrawal delirium, delirium related to seizures) continues to be a recommendation (12). In addition, if patients in critical care settings are already receiving high doses of parenteral lorazepam, the clinician will want to be alert for toxicity (e.g., renal dysfunction, hyperosmolar metabolic acidosis) associated with lorazepam's propylene glycol vehicle (45–47).

References

1. American Psychiatric Association: Practice guideline for the treatment of patients with delirium. Am J Psychiatry 1999; 156(5 suppl):1–20

2. Laurila JV, Pitkala KH, Strandberg TE, Tilvis RS: Detection and documentation of dementia and delirium in acute geriatric wards. Gen Hosp Psychiatry 2004; 26:31–35
[PubMed]

3. Ely EW, Stephens RK, Jackson JC, Thomason JW, Truman B, Gordon S, Dittus RS, Bernard GR: Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: a survey of 912 healthcare professionals. Crit Care Med 2004; 32:106–112
[PubMed]

4. McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E: Delirium predicts 12-month mortality. Arch Intern Med 2002; 162:457–463
[PubMed]

5. Trzepacz PT: The Delirium Rating Scale: its use in consultation-liaison research. Psychosomatics 1999; 40:193–204
[PubMed]

6. Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, Jimerson N: Validation of the Delirium Rating ScaleRevised–98: comparison with the Delirium Rating Scale and the Cognitive Test for Delirium. J Neuropsychiatry Clin Neurosci 2001; 13:229–242
[PubMed]

7. Turkel SB, Braslow K, Tavare CJ, Trzepacz PT: The Delirium Rating Scale in children and adolescents. Psychosomatics 2003; 44:126–129
[PubMed]

8. Schuurmans MJ, Shortridge-Baggett LM, Duursma SA: The Delirium Observation Screening Scale: a screening instrument for delirium. Res Theory Nurs Pract 2003; 17:31–50
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9. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI: Clarifying confusion: the Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med 1990; 113:941–948
[PubMed]

10. Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, Speroff T, Gautam S, Bernard GR, Inouye SK: Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001; 29:1370–1379
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12. Meagher DJ: Delirium: optimising management. BMJ 2001; 322:144–149
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15. Trzepacz PT, Meagher DJ: Delirium, in The American Psychiatric Publishing Textbook of Psychosomatic Medicine. Edited by Levenson JL. Washington, DC, American Psychiatric Publishing, 2005, pp 91–130

16. Tune LE: Anticholinergic effects of medication in elderly patients. J Clin Psychiatry 2001; 62(suppl 21):11–14

17. Mulsant BH, Pollock BG, Kirshner M, Shen C, Dodge H, Ganguli M: Serum anticholinergic activity in a community-based sample of older adults: relationship with cognitive performance. Arch Gen Psychiatry 2003; 60:198–203
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18. Yokota H, Ogawa S, Kurokawa A, Yamamoto Y: Regional cerebral blood flow in delirium patients. Psychiatry Clin Neurosci 2003; 57:337–339
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19. Trzepacz PT: Update on the neuropathogenesis of delirium. Dement Geriatr Cogn Disord 1999; 10:330–334
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20. Trzepacz PT: Is there a final common neural pathway in delirium? Focus on acetylcholine and dopamine. Semin Clin Neuropsychiatry 2000; 5:132–148
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21. Hanania M, Kitain E: Melatonin for treatment and prevention of postoperative delirium. Anesth Analg 2002; 94:338–339

22. Balan S, Leibovitz A, Zila SO, Ruth M, Chana W, Yassica B, Rahel B, Richard G, Neumann E, Blagman B, Habot B: The relation between the clinical subtypes of delirium and the urinary level of 6-SMT. J Neuropsychiatry Clin Neurosci 2003; 15:363–366
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23. Meagher DJ: Reply to "Optimising Management of Delirium." BMJ 2001; 322:1602

24. Flaherty JH, Tariq SH, Raghavan S, Bakshi S, Moinuddin A, Morley JE: A model for managing delirious older inpatients. J Am Geriatr Soc 2003; 51:1031–1035
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28. Kim KS, Pae CU, Chae JH, Bahk WM, Jun T: An open pilot trial of olanzapine for delirium in the Korean population. Psychiatry Clin Neurosci 2001; 55:515–519
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29. Breitbart W, Tremblay A, Gibson C: An open trial of olanzapine for the treatment of delirium in hospitalized cancer patients. Psychosomatics 2002; 43:175–182
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30. Sipahimalani A, Sime RM, Masand PS: Treatment of delirium with risperidone. Int J Geriatr Psychopharmacol 1997; 1:24–26

31. Furmaga KM, DeLeon OA, Sinha SB, Jobe TH, Gaviria M: Psychosis in medical conditions: response to risperidone. Gen Hosp Psychiatry 1997; 19:223–228
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32. Horikawa N, Yamazaki T, Miyamoto K, Kurosawa A, Oiso H, Matsumoto F, Nishimura K, Karasawa K, Takamatsu K: Treatment for delirium with risperidone: results of a prospective open trial with 10 patients. Gen Hosp Psychiatry 2003; 25:289–292
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34. Schwartz TL, Masand PS: Treatment of delirium with quetiapine. Prim Care Companion J Clin Psychiatry 2000; 2:10–12
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37. Al Samarrai S, Dunn J, Newmark T, Gupta S: Quetiapine for treatment-resistant delirium. Psychosomatics 2003; 44:350–351

38. Kim KY, Bader GM, Kotlyar V, Gropper D: Treatment of delirium in older adults with quetiapine. J Geriatr Psychiatry Neurol 2003; 16:29–31
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39. Kalisvaart KJ, de Jonghe J, Bogaards MJ, Burger BJ, van Gool PA, Egberts TC, Eikelenboom P: A placebo-controlled study of haloperidol prophylaxis for post-operative delirium in elderly hip-surgery patients. J Am Geriatr Soc 2003; 51(suppl 4):239–255

40. Wengel SP, Roccaforte WH, Burke WJ: Donepezil improves symptoms of delirium in dementia: implications for future research. J Geriatr Psychiatry Neurol 1998; 11:159–161
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41. Wengel SP, Burke WJ, Roccaforte WH: Donepezil for postoperative delirium associated with Alzheimer's disease. J Am Geriatr Soc 1999; 47:379–380
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42. Burt T: Donepezil and related cholinesterase inhibitors as mood and behavioral controlling agents. Curr Psychiatry Rep 2000; 2:473–478
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43. Gleason OC: Donepezil for postoperative delirium. Psychosomatics 2003; 44:437–438
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44. Dautzenberg PL, Wouters CJ, Oudejans I, Samson MM: Rivastigmine in prevention of delirium in a 65 year old man with Parkinson's disease. Int J Geriatr Psychiatry 2003; 18:555–556
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45. Yaucher NE, Fish JT, Smith HW, Wells JA: Propylene glycol–associated renal toxicity from lorazepam infusion. Pharmacotherapy 2003; 23:1094–1099
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46. Mullins ME, Barnes BJ: Hyperosmolar metabolic acidosis and intravenous lorazepam. N Engl J Med 2002; 347:857–858
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47. Reynolds HN, Teiken P, Regan ME, Habashi NM, Cottingham C, McCunn M, Scalea TM: Hyperlactatemia, increased osmolar gap, and renal dysfunction during continuous lorazepam infusion. Crit Care Med 2000; 28:1631–1634
[PubMed]

1. American Psychiatric Association: Practice guideline for the treatment of patients with delirium. Am J Psychiatry 1999; 156(5 suppl):1–20

2. Laurila JV, Pitkala KH, Strandberg TE, Tilvis RS: Detection and documentation of dementia and delirium in acute geriatric wards. Gen Hosp Psychiatry 2004; 26:31–35
[PubMed]

4. McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E: Delirium predicts 12-month mortality. Arch Intern Med 2002; 162:457–463
[PubMed]

5. Trzepacz PT: The Delirium Rating Scale: its use in consultation-liaison research. Psychosomatics 1999; 40:193–2041010477
[PubMed]

7. Turkel SB, Braslow K, Tavare CJ, Trzepacz PT: The Delirium Rating Scale in children and adolescents. Psychosomatics 2003; 44:126–1291010117
[PubMed]