Delirium management

Overdose of stimulants may lead to signs and symptoms of sympathetic overstimulation, including tremors, hypertension, fever, tachycardia, hyperreflexia, confusion, agitation, and frank psychosis or delirium. Management typically involves supportive measures to treat fever, severe hypertension, seizures, agitation, and other signs and symptoms. 

Antipsychotic medications are indicated in the treatment of acute and chronic psychotic disorders. These include schizophrenia, schizoaffective disorder, and manic states occurring as part of a bipolar disorder or schizoaffective disorder. The co-adminstration of antipsychotic medication with antidepressants has also been shown to increase the remission rate of severe depressive episodes that are accompanied by psychotic symptoms. Antipsychotic medications are frequently used in the management of agitation associated with delirium, dementia, and toxic effects of both prescribed medications (e.g. L-dopa used in Parkinson s disease) and illicit dtugs (e.g. cocaine, amphetamines, andPCP). They are also indicated in the management of tics that result from Gilles de la Tourette s syndrome, and widely used to control the motor and behavioural manifestations of Huntington s disease. 

Surprisingly, it appeared that there had been hardly any therapeutic progress in the management of belladonna poisoning since the 19 century, when opium was the most commonly used treatment. The first six decades of the 20 century spawned many new drugs, but no one seemed to have reported anything good for atropine delirium in mainstream medical journals. 

The medication of choice was for many years haloperidol (Haldol), a high potency antipsychotic, that can be given orally or by injection. When used, haloperidol should be administered in low doses (0.5-1.0mg) and only on an as-needed basis. Due to concerns regarding the tolerability of haloperidol in patients with dementia, its role in the management of agitation associated with delirium has largely been supplanted by atypical antipsychotics. A number of atypical antipsy-chotics are available by either an oral or intramuscular (injection) route of administiation. 

Antipsychotics. Dopamine-blocking antipsychotics can be used to manage the agitation and psychotic symptoms that accompany delirium. Generally, low doses of high potency antipsychotics such as haloperidol have been most often used, though risperidone, ziprasidone, and other atypical antipsychotics are gaining increased acceptance. Because, as we mentioned earlier, some evidence indicates... 

The Cochrane Collaboration reviewed interventions for delirium in patients with chronic cognitive impairment and concluded Delirium, though a frequent problem in the hospitalised elderly patient, is still managed empirically and there is no conclusive evidence in the literature to change practice at this time . 

Other Uses in Geriatric Patient Management of agitation secondary to delirium, antiemetic... 

Intravenous administration of low-dose, high-potency agents is also an option in certain clinical situations. For example, i.v. haloperidol, alone or in combination with i.v. lorazepam, has been safe and effective in managing delirium in critically ill, medical patients ( 152, 153). At times, effective doses of haloperidol may be as low as 0.5 to 1 mg when given by this route. Alternatively, droperidol may offer some advantages over haloperidol, including overall efficacy, safety, and rapidity of onset (.154). 

These are usually described as mild in intensity and fairly short in duration (i.e., a few days to a few weeks). None is considered life-threatening or permanently debilitating and, with the exception of the relatively rare occurrence of seizures, delirium, and/or psychosis, all are thought to be readily managed. 

In the management of anxiety, the cumulative effects of longer half-life BZDs often result in excessive sleepiness, apathetic states, and confusion (with or without paradoxical agitation). Thus, short- and intermediate-acting agents such as oxazepam, lorazepam, and alprazolam are preferable. Lower doses (e g., 0.5 to 1.0 mg of lorazepam 0.25 to 0.5 mg of alprazolam) are preferable. Agents with very short half-lives, such as midazolam and triazolam, are not well tolerated, especially in those with more severe neurocognitive disruption. In this context, low-dose antipsychotics were found more effective than lorazepam in the treatment of AIDS-related delirium (495). 

The main drugs in this section are the barbiturates which can be considered as dry drink , and the withdrawal effects are very similar to the withdrawal from alcohol. Full-blown delirium tremens and epileptic fits can be observed and will need, usually, in-patient management and close supervision and sedation. 

An overdose with an MAOI can produce a variety of effects including autonomic instability, hyperadrenergic symptoms, psychotic symptoms, confusion, delirium, fever, and seizures. Management of MAOI overdoses usually involves cardiac monitoring, vital support, and lavage. 

The treatment of patients during a delirium tremens episode includes the intravenous administration of another CNS depressant (usually diazepam) during the acute phase, followed by the oral administration of chlordiazepoxide or oxazepam. In addition, other medications and dietary management may become essential. 

In addition to acute and chronic schizophrenia, the neuroleptics are sometimes used in the management of mania, delirium, and severe agitation, whatever the cause of these symptom complexes. It must be noted that unlike parkinsonism, where a definite dysfunction in the DA system has been established, for schizophrenia and other psychiatric diseases, no unequivocal evidence has yet been presented to prove that there is a disturbance of the DA system (e.g., dopaminergic overactivity or receptor hypersensitivity). In untreated schizophrenics the production of DA metabolites is normal. Conflicting results have been obtained in studies of the DA receptors in schizophrenics (11,12,13), but in the case of patients who have not received neuroleptics, the receptor density and affinity appear to be normal (13). The "dopamine hypothesis" in these disorders derives from the beneficial effects of drugs that block DA receptors. 

The functional capacity of the brain is impaired. Irreversible damage may manifest in a measurable fallout of neuronal cell bodies. Often delirium tremens develops (usually triggered by alcohol withdrawal), which can be managed with intensive therapy (clomethiazole, haloperidol, among others). In addition, alcoholic hallucinations and Wernicke-Korsakow syndrome occur. All of these are desolate states. 

Ketamine often causes emergence delirium and disturbing dreaming. Benzodiazepines are often co-adminis-tered to attempt to manage this. The optimal dose of diazepam to add to ketamine-fentanyl field anaesthesia has been assessed in a randomized double-blind study in 400 patients from Vanuatu the optimal dose was 0.1 mg/ kg (436). 

Common symptoms of exposure include mydriasis, sinus tachycardia, hypertension or hypotension, anxiety, hallucinations, psychoses, choreoathetosis, delirium, seizures, dry mouth, flushed skin, decreased gastrointestinal motility, ileus, urinary retention, and hyperpyrexia. Anticholinergic agents may be detected in the urine, but this does not direct clinical management. Due to multiple plant variations, the alkaloid content differs greatly. 

In severe cases with delirium and shock corticosteroids may be given combined with antibiotics to treat toxic effects. Fluid and electrolyte replacement and correction of metabolic disturbances are important part of the management. 

---