DELIRIUM MANAGEMENT
Urgent Sedation for Severe Agitation • Haloperidol 5 mg, lorazepam 2 mg,+/- diphenhydramine 50 mg IM/SC • May repeat after 30 min. • Mix slowly in one syringe: 1. lorazepam, 2. haloperidol, 3. diphenhydramine Agitation in Alzheimer's / Vascular / Mixed Dementia Optimize Existing Medications: • Acetyl-cholinesterase inhibitors: Donepezil: 10 mg PO qhs • Rivastigmine: 9.5 mg/24 hr transdermal patch • NMDA receptor antagonist (memantine: 10 mg PO q12hr) First Choices • Trazodone: 50‒100 mg q1hr prn. Schedule q8hr based on previous day's prn need. Max 600 mg/dose/24 hr • Gabapentin: 100 mg q1hr prn. Schedule q8hr based on previous day's prn need. Max does 3600 mg/24 hr • Propranolol: 5 mg q8hr, titrate by 5 mg tid to effect as tolerated. Max dose: 320 mg/day. • Sertraline: 25 mg daily, titrate to effect by 25‒50 mg q/wk. Max dose 200 mg. Second Choices: Antipsychotics • Haloperidol: 1 mg q30min SC prn (q60min PO). Max 10 mg/dose, 100 mg/day. • Risperidone: 0.25 mg PO q1H prn. Max 6 mg/day. • Chlorpromazine: 50mg SC q30min prn (q60min PO/PR). Max 200 mg/dose 2000 mg/day. Note: Use lower, slower titrations in the elderly, frail, demented patients as safety allows.
Agitation in Dementia with Lewy Bodies (LBD) Optimize Existing Medications: • Acetyl-cholinesterase inhibitors: Donepezil: 10 mg PO qhs • Rivastigmine: 9.5 mg/24hr transdermal patch • NMDA receptor antagonist (memantine: 10 mg PO q12hr) First Choices • As for Alzheimer's/Vascular/Mixed dementias Second Choice • Quetiapine: 25mg q1hr prn. Max 600 mg/dose 1200 mg/day (LBD patient will be more sensitive to the adverse effects of antipsychotics: use lower doses and assess frequently) Agitation in Parkinson's Disease Associated Dementia First Steps: • Medication simplification • Reduce and possibly eliminate anti-Parkinson medications Second Choices
•Trazodone pm •Gabapentin prn
Third Choices • Cholinesterase inhibitor • SSRI • Propranolol Fourth Choice • Quetiapine Note: Dosing guidelines as above
Developed by Drs. Jeremy Hirst & Scott Irwin, Psychiatrists. Private Communication. Used with Permission
32 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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