Anticipate the possible occurrence of a delirium, certainly if there are prodromes, such as a reversal in the day and night rhythm, disorientation, restlessness and difficulty concentrating and thinking clearly.
Make use of the DOS scale as screening instrument.
Use the DSM-IV-TR criteria for the diagnosis of delirium.
Conduct a careful physical examination in order to identify treatable causes of the delirium; at a minimum, perform the following checks:
- temperature, pulse, blood pressure, skin turgor and respiratory rate
- pupil size, colour of the conjunctiva, skin and lips
- examination of the thorax, especially auscultation and percussion of the lungs
- percussion of the bladder (in order to exclude a full bladder as the cause of the restlessness)
- if needed, a digital rectal toucher (to exclude serious constipation as the cause of the restlessness)
- simple neurological examination (consciousness, signs of meningeal irritation, loss of motor function, reflexes)
Perform additional tests/examination such as urine or blood tests, chest X-ray, CT scan or MRI of the brain, lumbar punction.
Differentiate between a delirium and anxiety, depression, dementia and psychosis.
Think of other causes of restlessness such as a full bladder, constipation, pain that has not been dealt with sufficiently or difficulty breathing or side effects of medication.
Treat precipitating factors; pay particular attention to side effects of medications, withdrawal from medication and/or substances, metabolic abnormalities, infections and dehydration.
Do not confuse restlessness that results from pain with restlessness from a delirium, consider a reduction in the dose of opioids in case of a delirium. If this is not possible: consider opioid rotation (to this end, see the guideline Pain).
Explain the cause of the confusion, the changes in consciousness, cognition and behaviour to the patient and others in the patient's environment.
Ensure the environment is peaceful and provides opportunities for the patient to orientate themselves, talk calmly and clearly, guard the day and night rhythm, prevent the patient from causing themselves or others harm.
Discuss any protective measures that may be required and employ these as sparingly and as shortly as possible and deemed appropriate.
Treat confusion with haloperidol, starting dose 0.5-2 mg oralyl, buccally, intramuscularly, subcutaneously/intravenously, every half hour (with parenteral administration) until there is an effect. Maintenance dose: 1-5 mg/24 hours with a maximum of 10 mg/24 hours (parenteral) and 20 mg/24 hours if administration is oral, lower with elderly patients. As a general rule, haloperidol may be administered once per day for the night after reaching a stable situation. If haloperidol is contraindicated in relation to Parkinson's Disease: administer clozapine, dose: 12.5 mg twice daily.
Aside from antipsychotic drugs, treat any persistent restlessness with lorazepam. 1-4 mg tablet (injection fluid also possible) sublingually every 6 hours; if needed 1-4 mg s.c., i.m. or i.v.
If there is insufficient effect with haloperidol as specific D2 antagonist after 5-7 days, one of the following alternatives may be tried, because other neurotransmitter systems may also be disturbed with a delirium:
- 2.5-10 mg olanzapine orally 1-2 times daily, or 2.5-5 mg 1-2 times daily i.m.
- 0.5-1 mg risperidone orally twice daily, to a maximum of 2 mg twice per day
- 12.5-50 mg quetiapine orally 1-2 times per day.
- 1.5-3 mg rivastigmine orally twice daily or 4.6 mg/day transdermally
Consider palliative sedation in the case of a refractory delirium.