DELIRIUM MANAGEMENT
Attempt to reverse the underlying causes if consistent with context and goals of care. Concurrently treat associated symptoms. Non-Pharmacological Interventions
Pharmacological Interventions to Control Symptoms Potentially Reversible Delirium Irreversible Delirium Haloperidol ( non-sedating ) 1‒2 mg PO q1H PRN 1‒2 mg SC q30min PRN or IV q15min PRN Chlorpromazine ( sedating )
• Frequent orientation / orientation board • Cognitive exercises • Dim lighting • Natural daylight • Sensory AIDS, e.g., glasses, hearing aids • Familiar objects, pictures • Limit sensory over-stimulation
Lorazepam 1‒2 mg PO/Buccal q1H PRN 1‒2 mg SC q30min PRN or IV q15min PRN Midazolam Loading dose: 0.2 mg/kg IV/SC Maintenance dose: 0.075 mg/kg/hr IV/SC Phenobarbital Loading dose: 10‒30 mg / kg IV/SC/PO/PR Maintenance dose: 160‒800 mg PO/PR q8H or 10‒100 mg/hr IV/SC Propofol Start 1 mg/kg/hr Titrate in 0.5 mg/kg/hr steps within 15‒30 min Max in palliative medicine literature is 6 mg/kg/hr
50‒100 mg PO/PR q1H PRN 50‒100 mg SC q30min PRN or
• Consistent caregivers • Relaxation techniques
IV q1H by infusion PRN
Titrate to control symptoms: can double PRN dose if 3 doses ineffective Once controlled, for maintenance: • Schedule a daily dose based on total PRN doses needed to achieve goal in 24 hours ( t ½ of both is ≈ 24 hr ) • Continue PRN dosing as above
• Daily routine • Sleep hygiene • Range of motion or physical activity • Constant companions or family visitation • Leisure activities • Limit immobilization, e.g., catheters IV’s, restraints
Rethink doses, medications or diagnoses if ineffective after 3 PRN doses
Irwin et al. J Palliat Med 2013. PMID: 23480299. Used with Permission
31 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024
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