Delirium
Delirium - Summary
Delirium (acute confusional state) is a clinical syndrome characterized by disturbed consciousness, cognitive function, or perception, which has a sudden onset (usually hours to days) and fluctuating course. It can be classified into subtypes based on the person's symptoms:
Hypoactive delirium. The person has signs of apathy, sleepiness, and lethargy, and may be withdrawn.
Hyperactive delirium. The person has signs of agitation, restlessness, and aggression.
Mixed delirium. The person has signs of hypoactive and hyperactive delirium. This is the most common type of delirium.
The prevalence of delirium increases with increasing age.
A diagnosis of delirium requires the person to fulfil either the short Confusion Assessment Method (short-CAM) criteria for delirium or the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for delirium.
Delirium should be differentiated from dementia, although the relationship between the two is complex. Dementia, unlike delirium, usually has an insidious onset, progressive course (not fluctuating), and long duration. People with dementia do not have altered consciousness or impaired attention.
Most people with delirium are admitted to hospital for multidisciplinary management (including regular observation, treatment of the underlying causes, and alleviation of the symptoms).
Hospital admission may not be necessary if:
The symptoms of delirium are not harmful to the individual or others, and can be managed.
The predisposing factors of delirium can be identified and treated.
The person can receive constant supervision from a healthcare professional trained in the management of delirium.
Regular medical follow up can be arranged (for example within 1 or 2 days).
The benefits of being managed in the community outweigh the benefits of hospital admission (for example those on an end-of-life pathway or residing in a nursing care home).
Where possible any underlying precipitating factors should be identified, including:
Infection.
Drug adverse reaction.
Faecal impaction.
Urinary retention.
Electrolyte imbalance.
Pain.
Alcohol withdrawal.
Dementia.
Have I got the right topic?
This CKS topic is based on the guideline Delirium: diagnosis, prevention and management, published by the National Institute for Health and Clinical Excellence (NICE) [National Clinical Guideline Centre, 2010; NICE, 2010] and the guideline The prevention, diagnosis and management of delirium in older people: national guidelines published by the Royal College of Physicians and British Geriatric Society [Royal College of Physicians and British Geriatrics Society, 2006].
This CKS topic covers the diagnosis of delirium, identifying a cause of delirium, and the management of delirium in primary care.
This CKS topic does not cover the management of delirium in secondary care.
There are separate CKS topics on common comorbidities of delirium. See the CKS topics on Dementia and Depression.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
March 2012 — minor typographical error corrected in the management scenario. Issued in April 2012.
November 2010 to February 2011 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.
Update
New evidence
NHS Evidence published an evidence update on delirium in April 2012. [Free Full-text (pdf)]
Evidence-based guidelines
No new evidence-based guidelines since 1 October 2010.
HTAs (Health Technology Assessments)
No new HTAs since 1 October 2010.
Economic appraisals
No new economic appraisals relevant to England since 1 October 2010.
Systematic reviews and meta-analyses
Systematic reviews published since the last revision of this topic:
Clegg, A. and Young, J.B. (2011) Which medications to avoid in people at risk of delirium: a systematic review. Age and Aging 40(1), 23-29. [Abstract] [Free Full-text]
de Lange, E., Verhaak, P.F., and van der Meer, K. (2013) Prevalence, presentation and prognosis of delirium in older people in the population, at home and in long term care: a review. International Journal of Geriatric Psychiatry 28(2), 127-134. [Abstract]
Primary evidence
Randomized controlled trials published since the last revision of this topic:
Al-Aama, T., Brymer, C., Gutmanis, I., et al. (2011) Melatonin decreases delirium in elderly patients: A randomized, placebo-controlled trial. International Journal of Geriatric Psychiatry 26(7), 687-694. [Abstract]
Grover, S., Kumar, V., and Chakrabarti, S. (2011) Comparative efficacy study of haloperidol, olanzapine and risperidone in delirium. Journal of Psychosomatic Research 71(4), 277-281. [Abstract]
New policies
No new national policies or guidelines since 1 October 2010.
New safety alerts
No new safety alerts since 1 October 2010.
Changes in product availability
No changes in product availability since 1 October 2010.
Goals and outcome measures
Goals
To support primary healthcare professionals:
To diagnose delirium
To offer appropriate initial and subsequent management for the person with delirium
To refer the person with delirium, when appropriate, to other healthcare professionals
To ensure that symptoms, behavioural problems, and physical disabilities are addressed in partnership with the person and their carers
To ensure that psychotropic drugs are used appropriately
To provide effective psychosocial support for the person's family or carers
Background information
Definition
What is it?
Delirium (sometimes called 'acute confusional state') is a clinical syndrome characterized by disturbed consciousness, cognitive function, or perception, which has a sudden onset (usually hours to days) and fluctuating course [NICE, 2010].
Delirium can be classified into subtypes based on the person's symptoms [Meagher and Trzepacz, 2000; NICE, 2010]:
Hypoactive delirium. The person has signs of apathy, sleepiness, and lethargy, and may be withdrawn.
Hyperactive delirium. The person has signs of agitation, restlessness, and aggression.
Mixed delirium. The person has signs of hypoactive and hyperactive delirium.
For more information, see Making the diagnosis.
Prevalence
How common is it?
The prevalence of delirium varies depending on the patient population and study setting.
There are very few epidemiological studies of delirium outside hospital.
In care homes, the prevalence of delirium is estimated to be less than 20% [NICE, 2010].
A small, UK-based, community study found the prevalence of delirium was 0.4% in people 18–55 years of age, 1.1% in people 55–85 years of age, and 13.6% in people 85 years of age and older [Folstein et al, 1991].
The reported prevalence of delirium is greatly affected by the diagnostic criteria used.
A Canadian descriptive study investigating the effects of different diagnostic criteria on the prevalence of delirium in 155 people living in care homes found that the prevalence of delirium was 26.5% if the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) criteria were used and 45.8% if the Confusion Assessment Method (CAM) criteria were used (see Diagnostic criteria) [Voyer et al, 2009].
Mixed delirium is the commonest subtype of delirium [Ely et al, 2001].
Predisposing factors
What are the predisposing factors?
Predisposing factors
Age (65 years of age and older).
Cognitive impairment (for example dementia).
Severe illness (for example heart failure).
Physical frailty.
Visual impairment.
Surgery (especially recent orthopaedic surgery).
The risk of delirium is increased by the number of predisposing factors present.
[Inouye and Charpentier, 1996; Anonymous, 1999; Royal College of Physicians and British Geriatrics Society, 2006]
Precipitating factors
What factors can precipitate delirium?
The cause of delirium is almost always multifactorial [Royal College of Physicians and British Geriatrics Society, 2006; NICE, 2010].
Precipitating factors [Royal College of Physicians and British Geriatrics Society, 2006]
Infection (such as pneumonia, urinary tract infection).
Electrolyte imbalance (such as dehydration, renal failure, hyponatraemia).
Respiratory and cardiological disorders (such as pulmonary embolism, myocardial infarction, heart failure).
Neurological and endocrine disorders (such as thyroid dysfunction, subdural haematoma, encephalitis).
Gastroenterological and genitourinary problems (such as faecal impaction, malnutrition, urinary retention, bladder catheterization).
Severe pain.
Sensory deprivation (for example leaving the person without spectacles or hearing aids).
Relocation (such as moving people with impaired cognition to unfamiliar environments).
Sleep deprivation.
Alcohol withdrawal.
Medication.
Nearly all drugs can cause delirium in a person with risk factors for delirium.
The medicines most likely to cause delirium include benzodiazepines, opioids, anti-Parkinsonian drugs, tricyclic antidepressants, lithium, and corticosteroids. Other medicines include digoxin, antipsychotics, and beta-blockers [American Psychiatric Association, 2007].
Prognosis
What is the prognosis?
The prognosis of delirium is closely related to the underlying predisposing and precipitating factors of delirium [Dasgupta and Hillier, 2010; National Clinical Guideline Centre, 2010]. The following factors are associated with a poor prognosis of delirium:
Dementia or cognitive impairment.
Comorbidities.
Visual impairment.
Severe delirium.
Hypoxic illness.
Delirium frequently persists beyond treatment of the underlying cause.
A meta-analysis (search date: March 1992) of eight prospective studies (in 573 people) found that of the people with delirium discharged from hospital, only 50% had improved at 1 month, and at 6 months 31% still met the criteria for delirium. The authors suggested the persistence of cognitive impairment could be related to the underlying conditions, or to the development of a predisposing factor, such as dementia [Cole and Primeau, 1993].
There is increasing evidence that delirium is not only a transient, reversible confusion, but may lead to long-term cognitive impairment [MacLullich et al, 2009].
Complications
What are the complications?
Complications associated with delirium
Falls (impaired balance).
Poor mobility (leading to an increased risk of institutionalization).
Pressure sores.
Nosocomial infections.
Functional impairment.
Incontinence.
Malnutrition.
Dehydration.
[Royal College of Physicians and British Geriatrics Society, 2006; National Clinical Guideline Centre, 2010]
Diagnosis
Diagnosis of delirium and identification of underlying causes
Suspecting delirium
When should I suspect delirium?
Suspect delirium in people with a sudden change in their behaviour.
Behavioural changes typically occur within hours or days. Behavioural changes fluctuate during the course of a day and are typically worse at night.
Behavioural changes may affect the person's:
Social behaviour — lack of cooperation with reasonable requests; withdrawal; or alterations in communication, mood, and attitude.
Cognition — worsened concentration, slow responses, or confusion.
Perception — visual or auditory hallucinations.
Physical function — reduced mobility, reduced movement, restlessness, agitation, changes in appetite, or sleep disturbance.
If delirium is suspected, a further assessment is required to confirm the diagnosis.
Basis for recommendation
Basis for recommendation
Delirium presents as a sudden change in behaviour
This information is based on expert opinion in the guideline Delirium: diagnosis, prevention and management, published by the National Institute for Health and Clinical Excellence (NICE) [National Clinical Guideline Centre, 2010; NICE, 2010].
The symptoms-based approach to suspecting delirium is based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for delirium, and on the NICE guideline development group's clinical experience [American Psychiatric Association, 2000].
A further assessment is required to confirm the diagnosis of delirium
This recommendation is based on expert opinion in the guideline Delirium: diagnosis, prevention and management, published by the National Institute for Health and Clinical Excellence (NICE) [National Clinical Guideline Centre, 2010; NICE, 2010].
Confirming the diagnosis of delirium involves an assessment based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for delirium and the short Confusion Assessment Method (short-CAM) criteria for delirium.
Making the diagnosis
How should I diagnose delirium?
A diagnosis of delirium requires the person to fulfil the diagnostic criteria of either The short Confusion Assessment Method (short-CAM) criteria for delirium or The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for delirium.
Take a history where ever possible from the person and a carer or relative. People with delirium are often unable to provide an accurate history, but gathering information from the person slowly, in a quiet environment, should be attempted.
Determine whether the person has prior cognitive impairment. Differentiating between delirium and dementia can be difficult.
Diagnose delirium if:
The onset was sudden and the course is fluctuating. Delirium often develops over hours or days and behavioural changes increase and decrease in severity during the day. Behavioural changes of delirium are often worse at night.
There is inattention (for example spelling WORLD backwards with reduced ability to focus, or shifts in attention) or cognitive impairment. See Assessing cognition.
There is disorganized thinking (for example rambling or incoherent speech) or altered level of consciousness (for example the person may be agitated or lethargic).
The underlying cause can be identified (or all likely alternative diagnoses have been excluded).
Consider the different classifications of delirium (see Definition).
Do not miss the diagnosis of hypoactive delirium in a person who is apathetic, quiet, or withdrawn.
Diagnostic criteria
The short Confusion Assessment Method (short-CAM) criteria for delirium [Inouye et al, 1990].
Sudden onset and fluctuating course, and
Inattention (for example serial seven test with reduced ability to focus, or shifts in attention), and either
Disorganized thinking (for example rambling or incoherent speech), or
An altered level of consciousness (for example the person is agitated or lethargic)
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for delirium [American Psychiatric Association, 2000].
Confusion develops over a short period and fluctuates.
Disturbance of consciousness.
A change in cognition.
Evidence from the history, physical examination, or laboratory findings indicate that the disturbance is caused by direct physiologic consequences of a general medical condition. If there is insufficient evidence to support the last DSM-IV criterion, diagnose delirium provided the clinical features are consistent with delirium and cannot be attributed to another diagnosis.
Basis for recommendation
Basis for recommendation
These recommendations are based on the guideline Delirium: diagnosis, prevention and management, published by the National Institute for Health and Clinical Excellence (NICE) [National Clinical Guideline Centre, 2010; NICE, 2010,] and expert opinion in the guideline The prevention, diagnosis and management of delirium in older people: national guidelines, published by the Royal College of Physicians and British Geriatric Society [Royal College of Physicians and British Geriatrics Society, 2006].
Fulfil the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for delirium or the short Confusion Assessment Method (short-CAM) criteria for delirium to make a diagnosis of delirium
This recommendation are based on guideline Delirium: diagnosis, prevention and management, published by NICE [National Clinical Guideline Centre, 2010; NICE, 2010].
The DSM-IV criteria for delirium are considered the gold standard for diagnosing delirium.
A secondary data collection study investigating 322 people admitted to hospital in two different studies (a randomized controlled trial on the management of delirium and a prognosis study) compared the DSM-IV criteria with the DSM-III and International Classification of Diseases, 10th edition (ICD-10) criteria for delirium. The DSM-IV criteria for delirium were the most inclusive criteria for elderly people with or without dementia, with a sensitivity of 96% and specificity of 91%. DSM-IV was particularly useful for diagnosing people with hypoactive symptoms [Cole et al, 2003].
NICE evaluated four studies (all cross sectional) comparing the short-CAM test with the DSM-IV criteria for the diagnosis of delirium. The quality of the evidence was considered to be low to moderate. The short-CAM test had a sensitivity ranging from 43–90% and positive predictive values ranging from 76–100%. NICE concluded that the diagnostic accuracy of the short CAM test was acceptable for diagnosing delirium and should be offered as an alternative to DSM-IV [National Clinical Guideline Centre, 2010].
Take a history where ever possible from a carer or relative
The person with delirium is often unable to give an accurate history and may have no insight into their change in behaviour [Foreman and Milisen, 2004].
Determine whether the person has prior cognitive impairment
Establishing an account of the person’s prior cognitive state from a relative or carer is the most useful step in the assessment [Royal College of Physicians and British Geriatrics Society, 2006].
The relationship between delirium and dementia is complex, with both disorders resulting in an increased risk for the other [Fick et al, 2002].
The onset was sudden and the course is fluctuating
The sudden onset of a change in behaviour that fluctuates is an essential diagnostic criterion for delirium. Therefore, delirium should not be diagnosed without determining that the person's change in behaviour is sudden and fluctuating.
There is inattention or cognitive impairment
Cognitive screening tests allow for a structured assessment of the person's cognition (including attention, memory, orientation), so are necessary in the workup to confirm the diagnosis of delirium.
Cognitive screening tests will help differentiate between dementia and delirium [Royal College of Physicians and British Geriatrics Society, 2006].
There is disorganized thinking or altered level of consciousness
Three subtypes of delirium have been described based on the person's level of consciousness: hyperactive delirium, hypoactive delirium, or mixed delirium [Meagher and Trzepacz, 2000].
Classify the delirium as hyperactive delirium, hypoactive delirium, or mixed delirium
Three subtypes of delirium have been described in a review articles, depending on which symptoms or signs of delirium predominate [Meagher and Trzepacz, 2000].
Hypoactive delirium should not be missed
Delirium may be unrecognized by doctors and nurses in two thirds of people [Foreman and Milisen, 2004].
Healthcare professional often do not recognize delirium and may misdiagnose hypoactive delirium as depression [Meagher, 2001; Royal College of Physicians and British Geriatrics Society, 2006].
Assessing cognition
How should I assess a person's cognition?
Use a validated, standardized, cognitive screening test which is used consistently in the local area (such as the Abbreviated Mental Test or the Mini-Mental State Examination).
Cognitive screening tests do not diagnose delirium, but will help gather information to support a diagnosis. As delirium is often fluctuating, a normal performance on a test (at a single point in time) does not rule out the possibility of delirium, but would exclude dementia.
Perform cognitive screening tests sensitively. Careless questioning can alienate the person and exacerbate difficulties with behaviour.
Screening tests assess:
Orientation — ability to state the time, day, and month, and identify their surroundings.
Registration — ability to repeat the names of three objects (such as ball, pen, tie).
Attention and calculation — counting backwards by from 100 in sevens (serial sevens test), or from 20 to 1, or spell WORLD backwards.
Recall — ability to repeat the names of the three objects from earlier.
Interpreting the scores from cognitive screening tests requires clinical judgement, as they can be affected by such factors as educational level, language, and impairment of hearing or vision. For more information on cognitive screening tests, see the CKS topic on Dementia.
Basis for recommendation
Basis for recommendation
Use a cognitive screening test which is available and used consistently in the local area
This recommendation is based on what CKS considers to be good clinical practice. The use of a cognitive screening test that is widely used will help with reproducibility of results and understanding between healthcare professionals.
The Mini-Mental State Examination (MMSE) and the Abbreviated Mental Test (AMT) are widely used in clinical practice (mainly in hospital settings). The AMT is more practical for primary care but lacks validation in a primary care setting [Jitapunkul et al, 1991].
For more information of cognitive screening tests, see the CKS topic on Dementia.
Cognitive screening tests do not diagnose delirium, but will help gather information to support a diagnosis
This information is based on expert opinion in the guideline The prevention, diagnosis and management of delirium in older people: national guidelines, published by the Royal College of Physicians and British Geriatric Society [Royal College of Physicians and British Geriatrics Society, 2006].
Interpreting the scores from cognitive screening tests require clinical judgement
The MMSE is influenced by age and education level. There seems to be an inverse relationship between MMSE scores and age, ranging from a median score of 29 for those 18–24 years of age to a score of 25 for individuals over 80 years of age [Alberta Medical Association, 2009].
Identifying a cause
How should I identify a cause for delirium?
If the person requires hospital admission, do not delay admission to look for precipitating factors of delirium.
The cause of delirium is almost always multifactorial.
If drug toxicity is suspected, review medication (including over-the-counter drugs).
If an infection is suspected: record the person's temperature (elderly people may not show a rise their temperature during an infection); examine the person's chest, abdomen, skin, and central nervous system; and take blood to measure full blood count and C-reactive protein. If clinically indicated, consider urinalysis (for a urinary tract infection) and a chest X-ray (for a chest infection). See the CKS topics on Urinary tract infection (lower) - women, Urinary tract infection (lower) - men, and Chest infections - adult.
If faecal impaction is suspected, do a rectal examination.
If urinary retention is suspected, examine for a palpable bladder.
If a neurological disease is suspected, examine the neurological system, and check pupil size for possible subdural haematoma.
If alcohol abuse or withdrawal are suspected, look for signs of alcohol withdrawal, such as tremor or sweating, and take blood to measure liver function.
If pain is suspected, look for painful joints and limbs, and check for signs of bruising (especially if there is a history of a fall).
If hypoxia is suspected, check the person's oxygen saturation with pulse oximetry.
If clinically indicated, consider the following tests:
Urea and electrolytes.
Bone profile.
Blood glucose.
Thyroid function tests.
Vitamin B12 and folate.
Electrocardiography and serum troponin measurement (for an arrhythmia or myocardial infarction).
Basis for recommendation
Basis for recommendation
These recommendations are based on expert opinion in the guideline The prevention, diagnosis and management of delirium in older people: national guidelines, produced by the Royal College of Physicians and British Geriatric Society [Royal College of Physicians and British Geriatrics Society, 2006],and what CKS considers to be good clinical practice.
The multifactorial nature of delirium is often underemphasized. Studies that have accounted for the possibility of multiple causes have found that between two and six factors may be present in a person with delirium [Inouye and Charpentier, 1996].
Attempting to identify and treat a single cause is overly simplistic. Each person with delirium will need a detailed, repeated assessment for multiple causes [Inouye and Charpentier, 1996].
Differential diagnoses
What else might it be?
In someone with suspected delirium, assess for conditions with similar clinical features (as these conditions may coexist with delirium, their presence does not necessarily exclude delirium).
Dementia
Dementia, unlike delirium, usually has an insidious onset, progressive course (not fluctuating), and long duration.
People with dementia do not have altered consciousness or impaired attention (except in severe dementia or dementia with Lewy bodies).
See the CKS topic on Dementia.
Depression
Depression may present with similar features (such as apathy or lethargy) to delirium, especially hypoactive delirium.
Depression, unlike delirium, usually develops over weeks, and people with depression normally preserve a reasonable memory and orientation.
See the CKS topic on Depression.
Mental illness
Delirium can be associated with psychotic features, such as hallucinations. Hallucinations in delirium are typically visual and fluctuate, unlike schizophrenia where the hallucinations are usually auditory and persist.
People with mental illness usually do not have impaired memory or orientation, or an altered level of consciousness (unless they have taken illicit drugs or alcohol).
See the CKS topics on Schizophrenia and Bipolar disorder.
Thyroid disease
Hypothyroidism and hyperthyroidism may mimic hypoactive delirium and hyperactive delirium, respectively.
See the CKS topics on Hypothyroidism and Hyperthyroidism.
Basis for recommendation
Basis for recommendation
This information is based on expert opinion from several review articles [Farrell and Ganzini, 1995; Nicholas and Lindsey, 1995; Gleason, 2003; Borthwick et al, 2006], and expert opinion in the guideline The prevention, diagnosis and management of delirium in older people: national guidelines, published by the Royal College of Physicians and British Geriatric Society [Royal College of Physicians and British Geriatrics Society, 2006].
Management
Management
Scenario : Management: covers which people with delirium do not need admission to hospital; how to treat the underlying cause of delirium in people not needing hospital admission; how to manage confusion and challenging behaviours; and what advice, information, and follow up should be offered.
Scenario : Management
Scenario : Management of delirium
Admission
Which people with delirium need admission to hospital?
Most people with delirium are admitted to hospital for multidisciplinary management (including regular observation, treatment of the underlying causes, and alleviation of the symptoms).
Consider not admitting people with delirium to hospital, if ALL of the following are present:
The symptoms of delirium are not harmful to the individual or others, and can be managed.
The predisposing factors of delirium can be identified and treated.
The person can receive constant supervision from a healthcare professional trained in the management of delirium.
Regular medical follow up can be arranged (for example within 1 or 2 days).
People with delirium (such as those on an end-of-life pathway or residing in a nursing care home) may be managed at home, where the benefits of being managed in the community out weigh the benefits of hospital admission.
Basis for recommendation
Basis for recommendation
Most people with delirium are admitted to hospital for multidisciplinary management
This information is based on the expert opinion from review articles and national guidelines [Royal College of Physicians and British Geriatrics Society, 2006; National Clinical Guideline Centre, 2010].
Early recognition and investigation of delirium is challenging, and delirium is missed in two thirds of people in hospital.
Delirium often has multifactorial causes and multiple potential consequences. Therefore, multicomponent interventions and multidisciplinary working is the most appropriate management for people with delirium, which is best delivered in a 'ward' environment.
Consider not admitting people with delirium to hospital
CKS found no guidelines on which people with delirium require hospital admission. These recommendations are based on expert opinion from a review article [Meagher, 2001], and what CKS considers to be good clinical practice.
Delirium is serious and is often best managed in hospital. However, admitting the person to hospital for care must be balanced against the potentially deleterious effects of a sudden change in environment on elderly people or those who have cognitive impairment [Meagher, 2001].
Treating the cause(s)
How should I treat the underlying cause(s) of delirium?
Manage the underlying precipitating factors in people not being admitted.
Infection. For information on treating infections, see the CKS topics on Chest infections - adult, Urinary tract infection (lower) - women, Urinary tract infection (lower) - men, and Gastroenteritis.
Drug adverse reaction. Stop the drug if appropriate, or reduce the dose, or change the drug to an alternative.
Faecal impaction. Treat with laxatives, and encourage a good diet, adequate fluid intake, and mobility. See the section on Managing faecal loading/impaction in the CKS topic on Constipation.
Urinary retention. Insert a temporary urinary catheter for relief of symptoms and consider a possible underlying urinary tract infection. See Scenario : Urinary retention in the CKS topic on LUTS in men, age-related (prostatism).
Electrolyte imbalance. Treat the electrolyte imbalance, or refer to the appropriate specialist. See the CKS topics on Hyponatraemia, Hypercalcaemia, and Chronic kidney disease - not diabetic.
Pain. Identify the type of pain and treat appropriately with analgesia that is unlikely to worsen the delirium. See the CKS topic on Analgesia - mild-to-moderate pain.
Alcohol withdrawal. Most people will require admission to hospital for management. See Scenario : Dependence on alcohol in the CKS topic on Alcohol - problem drinking.
Dementia. If it is difficult to distinguish between delirium and dementia, treat the delirium first. Delirium is a serious medical problem and requires urgent intervention. See the CKS topic on Dementia.
If symptoms of delirium persists despite treatment of the underlying cause, look for other precipitating factors or predisposing factors (such as dementia), or consider seeking advice from a specialist in the diagnosis of delirium (such as an elderly care consultant or an old age psychiatrist).
Symptoms of delirium can persist for weeks after the cause has been treated. In some people, delirium may lead to persistent, long-term cognitive impairment. See Prognosis.
Basis for recommendation
Basis for recommendation
Treat the underlying cause
These recommendations are based on expert opinion in the guideline The prevention, diagnosis and management of delirium in older people: national guidelines, produced by the Royal College of Physicians and British Geriatric Society [Royal College of Physicians and British Geriatrics Society, 2006].
The most important approach to the management of delirium is the identification and treatment of the underlying cause. Early identification of delirium and prompt treatment of the underlying cause may reduce the severity and duration of delirium [Lundstrom et al, 2005].
Infection is one of the most frequent precipitants of delirium. If there is a high likelihood of infection, antibiotics should be commenced promptly, selecting a drug to which the likely infective organism will be sensitive.
Incriminated drugs should be withdrawn wherever possible. In the cases of opiates causing delirium, it may be possible to reduce the dose or change to an alternative [Alagiakrishnan and Wiens, 2004].
Electrolyte problems should be corrected promptly [George et al, 1997].
If it is difficult to distinguish between delirium and dementia, treat for delirium first
This recommendation is based on expert opinion in the guideline Delirium: diagnosis, prevention and management, published by the National Institute for Health and Clinical Excellence (NICE) [National Clinical Guideline Centre, 2010; NICE, 2010].
Differentiating between the diagnoses of delirium, delirium superimposed on dementia, or dementia alone can be difficult. However, delirium is a serious acute illness and is reversible, so should be given priority over a possible underlying diagnosis of dementia.
If symptoms persist, assess for another cause or risk factors
This recommendation is based on expert opinion in the guideline Delirium: diagnosis, prevention and management, published by NICE [National Clinical Guideline Centre, 2010; NICE, 2010].
If symptoms persist, consider seeking advice from a specialist
This recommendation is based on what CKS considers to be good clinical practice.
Managing confusion
How should confusion be managed?
For people with delirium not needing hospital admission, treat the underlying precipitating factor(s) of delirium.
To reduce confusion, advise:
That the person should be cared for in a good sensory environment.
Lighting should be appropriate for time of day.
The wearing of hearing aids and spectacles should be encouraged, if needed.
Noise should be kept to a minimum (such as alarms).
A reality-orientation approach.
Regular (at least three times a day) cues to improve personal orientation (for example explaining to the person who they are and where they are).
Use of clocks and calendars to improve orientation.
Continuity of care from carers and nursing staff.
Encouragement of visits from family and friends. Encourage family to bring in familiar objects and pictures from home.
To manage the symptoms of confusion, such as:
Wandering, advise:
The correction of possible causes of wandering (such as pain, thirst, or need for the toilet).
Distraction. Relatives should be encouraged to help as they often have information about the person allowing for meaningful distractions.
Avoiding restraints. Restraints often make delirium worse, and should only be used as a last resort if the person is at risk of harming themselves.
Rambling speech, advise:
Tactfully disagreeing (if the topic is not sensitive).
Changing the subject.
Acknowledging the person's feelings, but ignoring the content.
Basis for recommendation
Basis for recommendation
Good sensory environment and reality-orientation approaches
These recommendations are based on expert opinion in the guideline The prevention, diagnosis and management of delirium in older people: national guidelines, published by the Royal College of Physicians and British Geriatric Society [Royal College of Physicians and British Geriatrics Society, 2006] and a review article [Naughton et al, 2005].
People who have recovered from delirium have reported that simple but firm communication, reality orientation, a visible clock, and the presence of a relative all contribute to a heightened sense of control during delirium [Schofield, 1997].
The National Institute for Health and Clinical Excellence (NICE) evaluated six hospital-based, non-UK studies (three RCTs and three prospective cohort studies) investigating multi-component interventions compared with usual care in the treatment of delirium. NICE found that multi-component interventions were more effective than usual care, but did not make any specific recommendations owing to the low quality of the evidence [National Clinical Guideline Centre, 2010; NICE, 2010].
Most environmental risk factors showed no significant effect on the severity of delirium (for example giving the person a single room, having a family member present, or being in poorly lit surroundings). However, a greater number of room changes, absence of a clock or watch, and not wearing reading glasses if needed were reported to have a significant adverse effect on the severity of delirium.
Managing the symptoms of confusion
These recommendations are based on expert opinion in the guideline The prevention, diagnosis and management of delirium in older people: national guidelines, published by the Royal College of Physicians and British Geriatric Society [Royal College of Physicians and British Geriatrics Society, 2006].
Restraints have not been shown to prevent falls and may increase the risk of injury [O'Keeffe, 2004].
Managing challenging behaviour
How should challenging behaviour be managed?
For people with delirium not needing hospital admission, treat the underlying cause(s) of delirium.
If the person with delirium develops challenging behaviour (such as aggression, agitation, shouting):
Assess for, and address underlying causes for the person's behaviour (such as pain, thirst, or need for the toilet).
Move the person to a safe, low-stimulation environment (such as a quiet room), away from the factors which are causing the problem.
If the person is not considered at risk to themselves or others:
Use verbal and non-verbal de-escalation techniques (such as active listening, effective verbal responding, and redirection).
Use physical restraint only if it is necessary and is considered in the best interests of the person.
If the person is considered at risk to themselves or others, and verbal and non-verbal de-escalation techniques have failed.
Use low-dose oral drug treatment for up to 1 week to reduce aggression (not to sedate the person).
Avoid long-term use (due to adverse effects), high doses, and combinations of drugs.
Monitor the person every day until stable.
Drug options (off-label use) are a low dose of:
Oral haloperidol (0.5 mg to 4.0 mg daily).
Oral olanzapine (2.5 mg to 10 mg daily).
Haloperidol and olanzapine should be used with caution or not at all in people with Parkinson's disease or Lewy body dementia.
Oral lorazepam (0.5 mg to 3.0 mg daily) may be a better option in this situation.
For more information on prescribing haloperidol, olanzapine, and lorazepam, see Prescribing information.
Basis for recommendation
Basis for recommendation
These recommendations are based on guideline Delirium: diagnosis, prevention and management, published by the National Institute for Health and Clinical Excellence (NICE) [National Clinical Guideline Centre, 2010; NICE, 2010,] and expert opinion in the guideline The prevention, diagnosis and management of delirium in older people: national guidelines, published by the Royal College of Physicians and British Geriatric Society [Royal College of Physicians and British Geriatrics Society, 2006].
Assess for an underlying cause of challenging behaviour
People with dementia may have difficulty communicating pain, hunger, and other uncomfortable states. The development of agitation should prompt a thorough evaluation to identify a medical problem or a possible source of discomfort [American Psychiatric Association, 2007].
Verbal and non-verbal de-escalation techniques
De-escalation techniques are recommended in both national guidelines based on expert opinion [Harlow, 2009].
Medication
The recommendations to use haloperidol and olanzapine are based on the guideline Delirium: diagnosis, prevention and management, published by the National Institute for Health and Clinical Excellence (NICE) [National Clinical Guideline Centre, 2010; NICE, 2010,]. See Drug treatment.
The recommendation to consider lorazepam as an alternative in people with Parkinson's disease or Lewy bodies is based on expert opinion from the guideline The prevention, diagnosis and management of delirium in older people: national guidelines, published by the Royal College of Physicians and British Geriatric Society [Royal College of Physicians and British Geriatrics Society, 2006].
Advice and information
What advice and information should I provide for carers and relatives?
Offer printed information which:
Explains the clinical features of delirium.
Encourages carers or family to seek medical help if the person develops any sudden changes in their usual behaviour.
Explains that delirium is common and usually temporary.
Describes people's experience of delirium.
Advises the person and carers of support groups.
Sources of support, information, and leaflets that can be printed
Carers UK provides help for anyone caring for a sick, disabled, or elderly person at home: telephone 0808 808 7777, online at www.carersuk.org.
Princess Royal Trust for Carers provides help for anyone caring for a sick, disabled, or elderly person at home: telephone 0844 800 4361, online at www.carers.org.
The Office of the Public Guardian supports decision making, within the framework of the Mental Capacity Act 2005, for people who lack mental capacity or who would like to plan for their future: online at www.publicguardian.gov.uk.
Basis for recommendation
Basis for recommendation
This recommendation is based on expert opinion in the guideline Delirium: diagnosis, prevention and management, published by the National Institute for Health and Clinical Excellence (NICE) [National Clinical Guideline Centre, 2010; NICE, 2010].
NICE evaluated 11 observational studies investigating advice and information in the management of delirium. One study was UK based. The following themes for information sharing were apparent:
People need insight into the experience of delirium to promote their understanding and to decrease fear.
As relatives provide a link with reality and can facilitate communication, they require anticipatory information about the risk for delirium.
Following delirium, people appreciate the opportunity of discussing their experience of delirium and to be provided with reassurance.
Information and education to improve understanding of delirium and its effects might help to improve outcomes.
Follow up
How should I follow up a person who has had delirium?
Consider referring all people who have had delirium for post-delirium counselling.
People who have had delirium may recall symptoms after the episode has resolved, which can result in unpleasant 'flashbacks'.
Address ongoing risk factors for delirium.
If the person has cognitive impairment, refer to an old-age psychiatry team to exclude underlying dementia. The relationship between delirium and dementia is complex. It is unclear whether delirium is unmasking an unrecognized dementia, or initiating a process of cognitive decline. See Prognosis.
If the person has poor mobility, refer to a physiotherapist.
If the person has a poor swallow or malnutrition, refer to a speech and language therapist and a dietitian.
If the person has continence problems, refer to a district nurse for a continence assessment, and advise regular toileting.
If the person has inadequate home support, consider referring them to a social worker for an increased care package.
If the person has multiple comorbidities or severe illness, optimize treatment, or consider referring to a geriatrician.
Address family and carer stresses and comorbidity (such as depression). See Advice and information.
Basis for recommendation
Basis for recommendation
These recommendations are based on expert opinion in the guideline The prevention, diagnosis and management of delirium in older people: national guidelines, published by the Royal College of Physicians and British Geriatric Society [Royal College of Physicians and British Geriatrics Society, 2006], two review articles [Meagher, 2001; Young and Inouye, 2007], and what CKS considers to be good clinical practice.
Referral for post-delirium counselling
The psychological sequelae of delirium have not been studied enough, but depression and post-traumatic stress disorder have been described [Breitbart et al, 2002].
Most people dismiss the episode of delirium once it has passed, but a significant minority have lingering concerns that an episode of delirium may represent the first step towards loss of mental function and independence [Schofield, 1997].
Risk factors for delirium
Further episodes of delirium may be prevented by addressing risk factors [Royal College of Physicians and British Geriatrics Society, 2006].
Refer to an old-age psychiatry team
Liaison psychiatry services have a valuable role in preventing further delirium, especially in people with underlying cognitive impairment and challenging behaviours [RCP, 2005].
The relationship between delirium and dementia is complex, with both disorders resulting in an increased risk for each other [Fick et al, 2002].
Refer to social services
Following delirium, people may benefit from more intensive support at home [Rahkonen et al, 2001].
Family and carer support
Symptoms of delirium are often not fully resolved after treatment of the underlying cause(s), relatives frequently play crucial roles in planning and monitoring future care of people after a delirium episode.
Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).
Haloperidol
Haloperidol
Short-term treatment with haloperidol can be used in people with delirium who require immediate management of aggression if they pose a risk to themselves or others and verbal and non-verbal de-escalation techniques have failed.
The aim of drug treatment is to calm the person and reduce agitation or aggression; it is not to sedate.
Contraindications
Who should avoid using haloperidol?
Do not use haloperidol if the person:
Has Parkinson's disease or Lewy body dementia — antipsychotics worsen these conditions.
Is in a comatose state, or has central nervous system depression or neuromuscular weakness (such as myasthenia gravis).
Has a clinically significant cardiac disorder, such as:
Recent acute myocardial infarction.
Uncompensated heart failure or second- or third-degree heart block.
Arrhythmias treated with class IA antiarrhythmic drugs (for example disopyramide, procainamide, quinidine) or class III antiarrhythmic drugs (for example amiodarone, sotalol), or a history of ventricular arrhythmia or torsades de pointes.
QT interval prolongation.
Clinically significant bradycardia.
Uncorrected hypokalaemia.
Is taking other drugs that also cause QT interval prolongation (such as antiarrhythmics, tricyclic antidepressants, erythromycin) or hypokalaemia (diuretics), or increase haloperidol levels (ketoconazole, itraconazole).
Haloperidol should avoided where possible in the following groups of people. If the use of haloperidol cannot be avoided, close monitoring for adverse effects is required.
Epilepsy — antipsychotics lower the seizure threshold.
Depression — antipsychotics can worsen depression.
Hepatic impairment or a history of jaundice — start with low doses. Haloperidol is metabolized via the liver.
Renal impairment — start with low doses (increased cerebral sensitivity).
Basis for recommendation
These recommendations are based on information from the manufacturer's Summaries of Product Characteristics [MHRA, 2008].
Interactions
Interactions
The following interactions are common to all antipsychotics:
Drugs with a sedative action (such as alcohol, analgesics, tricyclic antidepressants, and sedating antihistamines) will enhance the sedative effects of antipsychotics.
Drugs with a hypotensive effect (for example antihypertensives) will enhance the hypotensive effect of antipsychotics.
Drugs that prolong the QT interval, such as antiarrhythmics, macrolides (for example erythromycin), and tricyclic antidepressants, may have a synergistic effect on the QT interval. Avoid co-prescribing drugs that prolong the QT interval. These drugs are contraindicated with sertindole therapy.
Diuretics may cause hypokalaemia, which may increase the risk of arrhythmias; monitor potassium levels in people taking diuretics.
Azole antifungals — haloperidol levels are increased by 30% or more by itraconazole.
Selective serotonin reuptake inhibitors — haloperidol levels are increased by 20–30% by fluoxetine and by 20–60% by fluvoxamine.
Carbamazepine
Carbamazepine reduces plasma levels of haloperidol and risperidone by half.
Carbamazepine levels are increased by haloperidol — monitor carbamazepine levels if these drugs are given together.
Tricyclic antidepressants — the metabolism of tricyclic antidepressants may be impaired by haloperidol.
Basis for recommendation
These recommendations are based on Stockley's drug interactions: a source book of interactions, their mechanisms, clinical importance and management [Baxter, 2008].
Dose
Dose
A dose of haloperidol 0.5 mg to 4.0 mg daily, in divided doses, is suggested.
The lowest effective dose should be used.
Basis for recommendation
The recommended dose is extrapolated from expert opinion on the dose of haloperidol to use for people with dementia with severe behavioural problems, where drug treatment is indicated [Burns and Iliffe, 2009].
Adverse effects
Adverse effects
Extrapyramidal symptoms (Parkinsonism, dystonic reactions, akathisia) are less common with olanzapine. Acute dystonias may occur early in treatment. Tardive dyskinesia may develop during therapy or after the drug has been discontinued.
Hormonal effects of antipsychotic neuroleptic drugs include hyperprolactinaemia, which may cause galactorrhoea and gynaecomastia.
Cardiac adverse effects
Dose-related hypotension is uncommon but can occur, particularly in elderly people, who are more susceptible to the sedative and hypotensive effects.
Rarely, QT interval prolongation — the most widely reported cardiac conduction defect caused by antipsychotics and considered to be a class effect. It increases the risk of torsades de pointes, a potentially fatal arrhythmia.
Venous thromboembolism (VTE) — antipsychotic use may be associated with an increased risk of VTE.
Data are insufficient to determine any difference in risk between second-generation and first-generation antipsychotics, or between individual drugs.
All possible risk factors for VTE should be identified before and during antipsychotic treatment and preventive measures undertaken.
Gastrointestinal effects — nausea, loss of appetite, weight changes, and dyspepsia have been reported with haloperidol.
Reduced seizure threshold — seizures are a recognized adverse effect of antipsychotics (the higher the dose, the greater the risk).
Other adverse effects — haloperidol may impair alertness, particularly with higher doses at the start of treatment, and may be potentiated by alcohol.
Neuroleptic malignant syndrome — a very rare (in less than 1% of people) but life-threatening adverse effect that can occur with any antipsychotic.
Symptoms include hyperthermia, muscle rigidity, autonomic instability, and fluctuating consciousness.
Mortality without treatment is 20%; urgent medical treatment is therefore needed.
Basis for recommendation
This information is mainly based on published expert opinion from the Maudsley Prescribing Guidelines [Taylor et al, 2007].
The information regarding VTE is taken from recently published guidance from the Medicines and Healthcare products Regulatory Agency [MHRA, 2009].
The information regarding QT interval prolongation is taken from a published review of antipsychotics by the Medicines and Healthcare products Regulatory Agency [MHRA, 2006].
Olanzapine
Olanzapine
Short-term treatment with olanzapine can be used in people with delirium who require immediate management of aggression if they pose a risk to themselves or others and verbal and non-verbal de-escalation techniques have failed.
The aim of drug treatment is to calm the person and reduce agitation or aggression; it is not to sedate.
Contraindications
Who should avoid using olanzapine?
Do not use olanzapine if the person has:
Parkinson's disease, Lewy body dementia, or myasthenia gravis — antipsychotics worsen these conditions. Lorazepam is a better option.
Angle-closure glaucoma.
Olanzapine should avoided where possible in the following groups of people. If use of olanzapine cannot be avoided, close monitoring for adverse effects is required.
Prostatic hypertrophy or paralytic ileus — olanzapine may worsen these.
Epilepsy — antipsychotics lower the seizure threshold.
Diabetes mellitus — olanzapine may exacerbate hyperglycaemia.
People with cardiovascular disease.
The risk of QT interval prolongation is greatest in people with clinically significant cardiac disorders, such as recent myocardial infarction, a history of arrhythmias or heart block, uncompensated heart failure, or uncorrected hypokalaemia, or in people taking other drugs that also cause QT interval prolongation.
Depression — antipsychotics can worsen depression.
Hepatic impairment or a history of jaundice — start with low doses. Olanzapine is metabolized via the liver.
Renal impairment — start with low doses (increased cerebral sensitivity).
Basis for recommendation
These recommendations are based on information from the manufacturer's Summaries of Product Characteristics [ABPI Medicines Compendium, 2010].
Interactions
Interactions
The following interactions are common to all antipsychotics:
Drugs with a sedative action (such as alcohol, analgesics, tricyclic antidepressants, and sedating antihistamines) will enhance the sedative effects of antipsychotics.
Drugs with a hypotensive effect (for example antihypertensives) will enhance the hypotensive effect of antipsychotics.
Drugs that prolong the QT interval, such as antiarrhythmics, macrolides (for example erythromycin), and tricyclic antidepressants, may have a synergistic effect on the QT interval. Avoid co-prescribing drugs that prolong the QT interval. These drugs are contraindicated with sertindole therapy.
Diuretics may cause hypokalaemia, which may increase the risk of arrhythmias; monitor potassium levels in people taking diuretics.
Smoking induces the metabolism of olanzapine. If the person stops smoking, monitor for increased adverse effects.
Olanzapine levels are increased by fluoxetine, fluvoxamine, paroxetine, sertraline, and possibly citalopram.
Carbamazepine also reduces levels of olanzapine.
Basis for recommendation
These recommendations are based on Stockley's drug interactions: a source book of interactions, their mechanisms, clinical importance and management [Baxter, 2008].
Dose
Dose
A dose of olanzapine 2.5 mg to 10 mg daily is suggested.
The lowest effective dose should be used.
Basis for recommendation
The recommended dose is extrapolated from expert opinion on the dose of olanzapine to use for people with dementia with severe agitation, where drug treatment is indicated [Burns and Iliffe, 2009].
Adverse effects
Adverse effects
Extrapyramidal symptoms (Parkinsonism, dystonic reactions, akathisia) are less common with olanzapine than with haloperidol. Acute dystonias may occur early in treatment. Tardive dyskinesia may develop during therapy or after the drug has been discontinued.
Hormonal effects of antipsychotic neuroleptic drugs include hyperprolactinaemia, which may cause galactorrhoea and gynaecomastia.
Sedation — olanzapine is less sedating than many antipsychotics but may impair alertness, particularly with higher doses at the start of treatment, and may be potentiated by alcohol.
Anticholinergic effects, such as dry mouth, blurred vision, urinary retention, constipation, and cutaneous flushing — are more common with olanzapine than with haloperidol.
Cardiac adverse effects
Dose-related hypotension is uncommon but can occur, particularly in elderly people, who are more susceptible to the sedative and hypotensive effects.
Rarely, QT interval prolongation — the most widely reported cardiac conduction defect caused by antipsychotics and considered to be a class effect. It increases the risk of torsades de pointes, a potentially fatal arrhythmia.
Venous thromboembolism (VTE) — antipsychotic use may be associated with an increased risk of VTE.
Data are insufficient to determine any difference in risk between second-generation and first-generation antipsychotics, or between individual drugs.
All possible risk factors for VTE should be identified before and during antipsychotic treatment and preventive measures undertaken.
The following adverse effects are more of an issue with long-term rather than short-term use:
Weight gain — common with all antipsychotics, but more frequent with olanzapine than with haloperidol.
Dyslipidaemia — olanzapine increases lipid levels.
Impaired glucose tolerance — hyperglycaemia, and sometimes diabetes, can occur in people taking long-term olanzapine.
Hyperprolactinaemia, which may cause galactorrhoea and gynaecomastia, is uncommon with olanzapine.
Neuroleptic malignant syndrome — a very rare (in less than 1% of people) but life-threatening adverse effect that can occur with any antipsychotic.
Symptoms include hyperthermia, muscle rigidity, autonomic instability, and fluctuating consciousness.
Mortality without treatment is 20%; urgent medical treatment is therefore needed.
Basis for recommendation
This information is mainly based on published expert opinion from the Maudsley Prescribing Guidelines [Taylor et al, 2007].
The information regarding VTE is taken from recently published guidance from the Medicines and Healthcare products Regulatory Agency [MHRA, 2009].
The information regarding QT interval prolongation is taken from a published review of antipsychotics by the Medicines and Healthcare products Regulatory Agency [MHRA, 2006].
Lorazepam
Lorazepam
Short-term treatment with lorazepam can be used in people with delirium who require immediate management of aggression if they pose a risk to themselves or others and verbal and non-verbal de-escalation techniques have failed.
The aim of drug treatment is to calm the person and reduce agitation or aggression; it is not to sedate.
Contraindications
Who should not receive lorazepam?
Do not use lorazepam if the person has:
Severe hepatic impairment.
Respiratory depression, marked neuromuscular respiratory weakness (including unstable myasthenia gravis), or sleep apnoea syndrome.
Basis for recommendation
This information is derived from the British National Formulary [BNF 60, 2010].
Interactions
What key drug interactions of lorazepam should I be aware of?
Alcohol should be avoided when taking lorazepam. Alcohol can increase the sedative effects of lorazepam.
Drugs that have a central nervous system (CNS) depressant effect — additive CNS depressant effects occur when lorazepam is given with other medications that produce CNS depressant effects (such as barbiturates, antipsychotics, sedatives, antidepressants, sedative antihistamines, and anticonvulsants). Concomitant use is not recommended.
Basis for recommendation
This information is derived from the British National Formulary [BNF 60, 2010].
Dose
What dose of lorazepam is normally prescribed?
A dose of lorazepam 0.5 mg to 3.0 mg daily, in divided doses, is suggested.
The lowest effective dose should be used.
Basis for recommendation
The recommended dose is based on the dose of lorazepam for people with delirium who also have Parkinson's disease or Lewy body dementia advised in the guideline The prevention, diagnosis and management of delirium in older people: national guidelines, published by the Royal College of Physicians and British Geriatric Society [Royal College of Physicians and British Geriatrics Society, 2006].
Adverse effects
What adverse effects may occur with lorazepam?
Drowsiness and lightheadedness (which usually occur the next day), confusion, ataxia, and muscle weakness.
Occasionally, people may also experience headaches, vertigo, hypotension, salivation changes, gastrointestinal disturbances, tremor, incontinence, urinary retention, and jaundice.
Basis for recommendation
This information is derived from the British National Formulary [BNF 60, 2010].
Evidence
Evidence
Supporting evidence
This section summarizes the evidence that supports the use of drug treatments for challenging behaviour in people with delirium.
Drug treatment
Evidence on drug treatment for challenging behaviour
The National Institute for Health and Clinical Excellence (NICE) evaluated five hospital-based studies from outside the UK to investigate antipsychotics in the treatment of delirium, and found that antipsychotics should be considered after other treatments have been tried as the benefits (reduced mortality) outweigh the risks (increased risk of stroke) [National Clinical Guideline Centre, 2010].
There was uncertainty around the quality of the evidence.
The studies compared the use of antipsychotics to no treatment, or to an alternative antipsychotic.
One randomized controlled trial (RCT) showed a significant improvement in delirium (relative risk [RR] 3.95, 95% CI 1.75 to 8.90) with haloperidol compared with no treatment at 7 days.
One RCT showed a significant recovery from delirium with olanzapine compared with no treatment at 7 days (RR 3.68, 95% CI 1.63 to 8.33).
A meta-analysis of two studies (one RCT and one quasi-RCT) showed no significant difference in recovery from delirium between the haloperidol and olanzapine groups (RR 0.99, 95% CI 0.80 to 1.21).
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of delirium.
Search dates
Dates not restricted — October 2010
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
exp delirium/, delirium.tw, exp confusion/, confusion.tw,
exp diagnosis/, diagnostic criteria.tw, exp risk factors/, incidence/, prevalence/
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSh subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
National Guidelines Clearinghouse
British Columbia Medical Association
Institute for Clinical Systems Improvement
Guidelines International Network
National Library of Guidelines
National Health and Medical Research Council (Australia)
University of Michigan Medical School
Michigan Quality Improvement Consortium
Royal Australian College of General Practitioners
National Resource for Infection Control
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
Driver and Vehicle Licensing Agency
NHS Plus (occupational health practice)
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
DynaMed
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
Sources of medicines information
The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.
British National Formulary (BNF)
electronic Medicines Compendium (eMC)
European Medicines Agency (EMEA)
References
ABPI Medicines Compendium (2010) Summary of product characteristics for Zyprexa 2.5mg, 5mg, 7.5mg, 10mg, 15mg, and 20mg coated tablets. Zyprexa Velotab 5mg, 10mg, 15mg, and 20mg orodispersible tablets. Electronic Medicines Compendium..Datapharm Communications Ltd.www.medicines.org.uk [Free Full-text]
Alagiakrishnan, K. and Wiens, C.A. (2004) An approach to drug induced delirium in the elderly. Postgraduate Medical Journal 80(945), 388-393. [Abstract] [Free Full-text]
Alberta Medical Association (2009) Guideline for cognitive impairment: is this dementia? Symptoms to diagnosis. ..Alberta Medical Association.www.topalbertadoctors.org [Free Full-text]
American Psychiatric Association (Ed.) (2000) Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th edn. Washington, DC: American Psychiatric Association.
American Psychiatric Association (2007) Practice guidelines for the treatment of patients with Alzheimer's disease and other dementias. .2nd edn..www.psychiatryonline.com [Free Full-text]
Anonymous (1999) Practice guideline for the treatment of patients with delirium. American Psychiatric Association. American Journal of Psychiatry 156(5 Suppl), 1-20.
Baxter, K. (Ed.) (2008) Stockley's drug interactions: a source book of interactions, their mechanisms, clinical importance and management. 8th edn. London: Pharmaceutical Press.
BNF 60 (2010) British National Formulary. 60th edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.
Borthwick, M., Bourne, R., Craig, M. et al. (2006) Detection, prevention and treatment of delirium in critically ill patients. ..United Kingdom Clinical Pharmacy Association.www.ukcpa.org [Free Full-text]
Breitbart, W., Gibson, C. and Tremblay, A. (2002) The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses. Psychosomatics 43(3), 183-194. [Abstract]
Burns, A. and Iliffe, S. (2009) Dementia. BMJ 338, b75.
Cole, M.G. and Primeau, F.J. (1993) Prognosis of delirium in elderly hospital patients. Canadian Medical Association Journal 149(1), 41-46. [Abstract] [Free Full-text]
Cole, M.G., Dendukuri, N., McCusker, J. and Han, L. (2003) An empirical study of different diagnostic criteria for delirium among elderly medical inpatients. Journal of Neuropsychiatry and Clinical Neurosciences 15(2), 200-207. [Abstract] [Free Full-text]
Dasgupta, M. and Hillier, L.M. (2010) Factors associated with prolonged delirium: a systematic review. International Psychogeriatrics 22(3), 373-394. [Abstract]
Ely, E.W., Inouye, S.K., Bernard, G.R. et al. (2001) Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 286(21), 2703-2710. [Abstract] [Free Full-text]
Farrell, K.R. and Ganzini, L. (1995) Misdiagnosing delirium as depression in medically ill elderly patients. Archives of Internal Medicine 155(22), 2459-2464. [Abstract]
Fick, D.M., Agostini, J.V. and Inouye, S.K. (2002) Delirium superimposed on dementia: a systematic review. Journal of the American Geriatrics Society 50(10), 1723-1732. [Abstract]
Folstein, M.F., Bassett, S.S., Romanoski, A.J. and Nestady, G. (1991) The epidemiology of delirium in the community: the Eastern Baltimore Mental Health Survey. International Psychogeriatrics 3(2), 169-176. [Abstract]
Foreman, M. and Milisen, K. (2004) Improving recognition of delirium in the elderly. Primary Psychiatry 11, 46-50. [Free Full-text]
George, J., Bleasdale, S. and Singleton, S.J. (1997) Causes and prognosis of delirium in elderly patients admitted to a district general hospital. Age Ageing 26(6), 423-427. [Abstract] [Free Full-text]
Gleason, O.C. (2003) Delirium. American Family Physician 67(5), 1027-1034. [Abstract] [Free Full-text]
Harlow, W. (2009) Prevention and management of violence and aggression - promoting safe and therapeutic services in older people's mental health. ..National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
Inouye, S.K. and Charpentier, P.A. (1996) Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. Journal of the American Medical Association 275(11), 852-857. [Abstract]
Inouye, S.K., van Dyck, C.H., Alessi, C.A. et al. (1990) Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Annals of Internal Medicine 113(12), 941-948. [Abstract]
Jitapunkul, S., Pillay, I. and Ebrahim, S. (1991) The abbreviated mental test: its use and validity. Age & Ageing 20(5), 332-336. [Abstract]
Lundstrom, M., Edlund, A., Karlsson, S. et al. (2005) A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. Journal of the American Geriatrics Society 53(4), 622-628. [Abstract]
MacLullich, A.M., Beaglehole, A., Hall, R.J. and Meagher, D.J. (2009) Delirium and long-term cognitive impairment. International Review of Psychiatry 21(1), 30-42. [Abstract]
Meagher, D.J. (2001) Delirium: optimising management. BMJ 322(7279), 144-149. [Free Full-text]
Meagher, D.J. and Trzepacz, P.T. (2000) Motoric subtypes of delirium. Seminars in Clinical Neuropsychiatry 5(2), 75-85. [Abstract]
MHRA (2006) Pharmacovigilance Working Party public assessment report on neuroleptics and cardiac safety, in particular QT prolongation, cardiac arrhythmias, ventricular tachycardia and torsades de pointes. ..Medicines and Healthcare products Regulatory Agency.www.mhra.gov.uk [Free Full-text]
MHRA (2008) Haloperidol 0.5mg, 1.5mg, 5mg, 10mg and 20mg tablets PL 04416/0531-5. ..Medicines and Healthcare products Regulatory Agency.www.mhra.gov.uk [Free Full-text]
MHRA (2009) Antipsychotics: risk of venous thromboembolic events. Drug Safety Update 2(11), 2. [Free Full-text]
National Clinical Guideline Centre (2010) Delirium: diagnosis, prevention and management. ..National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
Naughton, B.J., Saltzman, S., Ramadan, F. et al. (2005) A multifactorial intervention to reduce prevalence of delirium and shorten hospital length of stay. Journal of the American Geriatrics Society 53(1), 18-23. [Abstract]
NICE (2010) Delirium: diagnosis, prevention and management. ..National Institute for Health and Clinical Excellence.www.nice.org.uk [Free Full-text]
Nicholas, L.M. and Lindsey, B.A. (1995) Delirium presenting with symptoms of depression. Psychosomatics 36(5), 471-479. [Abstract]
O'Keeffe, S.T. (2004) Down with bedrails? Lancet 363(9406), 343-344.
Rahkonen, T., Eloniemi-Sulkava, U., Paanila, S. et al. (2001) Systematic intervention for supporting community care of elderly people after a delirium episode. International Psychogeriatrics 13(1), 37-49. [Abstract]
RCP (2005) Who cares wins. Improving the outcome for older people admitted to the general hospital: Guidelines for the development of Liaison Mental Health Services for older people. ..Royal College of Psychiatrists.www.rcpsych.ac.uk [Free Full-text]
Royal College of Physicians and British Geriatrics Society (2006) The prevention, diagnosis and management of delirium in older people: national guidelines. ..Royal College of Physicians.www.rcplondon.ac.uk [Free Full-text]
Schofield, I. (1997) A small exploratory study of the reaction of older people to an episode of delirium. Journal of Advanced Nursing 25(5), 942-952. [Abstract]
Taylor, D., Paton, C. and Kerwin, R. (2007) The Maudsley prescribing guidelines. London: Informa Healthcare.
Voyer, P., Richard, S., Doucet, L. and Carmichael, P.H. (2009) Detecting delirium and subsyndromal delirium using different diagnostic criteria among demented long-term care residents. Journal of the American Medical Directors Association 10(3), 181-188. [Abstract]
Young, J. and Inouye, S.K. (2007) Delirium in older people. BMJ 334(7598), 842-846. [Abstract]