Haloperidol delirium

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. 

Delusions/Psychosis. Demented patients who are acutely psychotic and agitated should be treated in much the same manner as demented patients with delirium. Low doses of a high potency conventional antipsychotic like haloperidol were once preferred. This was mainly because it can be given both orally and by injection. In recent years, the atypical antipsychotic ziprasidone, which is now also available in oral and injectable forms, has superseded haloperidol as the preferred agent when treating the acutely psychotic and agitated patient with dementia. As previously noted, ziprasidone affords the same tranquilizing benefit as haloperidol, it can now be administered via injection when necessary, and it avoids the problematic extrapyramidal symptoms of haloperidol to which patients with dementia are often keenly sensitive. 

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... 

Other indications. Acutely, there is sedation with anxiolysis after neurolep-tization has been started. This effect can be utilized for psychosomatic uncoupling in disorders with a prominent psychogenic component neuroleptanalgesia (p. 216) by means of the buty-rophenone droperidol in combination with an opioid tranquilization of overexcited, agitated patients treatment of delirium tremens with haloperidol as well as the control of mania (see p. 234). 

Haloperidol is one of the most actively used modem neuroleptics. Its high antipsychotic activity is combined with a moderate sedative effect. It effectively stops various types of psychomotor excitement. It is used for schizophrenic psychoses, manic, paranoid, and delirious conditions, depression, psychomotor excitement of various origins, and for delirium and hallucinations of different origin. The most common synonyms are haldol, vezadol, linton, and others. 

Han CS, Kim YK. A double-blind trial of risperidone and haloperidol for the treatment of delirium. Psychoso-matics 2004 45(4) 297-301. 

Because of multiple receptor actions, which occur at different concentrations, different neuroleptics have different action profiles. There are many classifications for neuroleptic drugs, the least useful of which is probably based on their chemical structure. Other classifications include linear classifications based on the propensity to cause EPS, or multidimensional ones such as the Liege star which combines information on three positive effects (anti-autistic, antiproductive, antipsychotic), and three negative (hypotensive, extrapyramidal, sedative). In a general way, the more sedative neuroleptics such as levomepromazine, used more to treat acute agitation states, cause more hypotension related to alpha blockade, whereas those that act best on delirium (productive states) such as haloperidol tend to cause more EPS. 

Blitzstein, S.M. and Brandt, G.T. (1997) Extrapyramidal symptoms from intravenous haloperidol in the treatment of delirium. Am Psychiatry 154 1474-1475. 

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). 

Breitbart W, Marotta R, Platt MM, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry 1996 153 231-237. 

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. 

A 62-year-old woman became delirious when lithium at therapeutic concentrations was added to valproate, haloperidol, and biperiden (232). The delirium resolved after all drugs were withdrawn, but 6 months later she still had choreoathetoid movements. 

A pharmacodynamic drug interaction could not be excluded when a 60-year-old man developed delirium at a serum lithium concentration of 0.97 mmol/1 when taking lithium and haloperidol (158). 

Skrobik YK, Bergeron N, Dumont M, Gottfried SB. Olanzapine vs haloperidol treating delirium in a critical care setting. Intensive Care Med 2004 30 444-9. 

A 64-year-old woman underwent coronary artery bypass surgery and was given intravenous haloperidol for agitation and to avoid postoperative delirium she developed torsade de pointes (15). 

Several cases of torsade de pointes have been reported with intravenous haloperidol used with lorazepam to treat delirium (SEDA-18, 30) (SEDA-18, 47). Acid mucopolysaccharide deposition may be associated with neuroleptic drug treatment as a possible mechanism contributing to rare cardiovascular adverse events (57). 

A 37-year-old man who had abused metamfetamine, paint thinner, psychotomimetic drugs, and alcohol for 20 years was given chlorpromazine, haloperidol, and fluni-trazepam just before surgery. After spinal anesthesia he was given propofol 5 mg/kg/hour intravenously. However, euphoria and excitement occurred 10 minutes after the start of the infusion and he had excitement, hallucinations, and delirium. His symptoms were suppressed by intravenous haloperidol 5 mg. 

When paroxetine was introduced in a patient taking benzatropine and haloperidol, the circulating concentrations of benzatropine rose and delirium occurred (SEDA-22, 157) (1). 

Benztropine Seven patients developed delirium when given fluoxetine, paroxetine, or sertraline with benztropine in the presence of perphenazine or haloperidol. Other patients remained symptom-free. 

Although phenothiazines, clonidine, carbamazepine, y-hydroxybutyric acid, and valproic acid may reduce symptoms of alcohol withdrawal, their ability to prevent seizures or delirium tremens has yet to be proven, and in fact, the phenothiazines may lower the seizure threshold. Other drugs used to treat symptoms of alcohol withdrawal include other barbiturates, alcohol itself, sympatholytics such as atenolol, thiamine, magnesium, and other neuroleptics such as haloperidol. At the time of this writing, gabapentin is being compared to lorazepam for acute alcohol withdrawal in a phase II clinical trial. 

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