Delirium
Clinical Snapshot
Delirium is an acute, fluctuating disturbance of attention and awareness, together with an additional change in cognition (memory, orientation, language, visuospatial ability, or perception), that develops over hours to a few days and is not better explained by a pre-existing or evolving neurocognitive disorder.[1] It results from an interaction between predisposing vulnerability (older age, pre-existing cognitive impairment, sensory impairment, frailty) and one or more precipitating insults (infection, metabolic derangement, drug toxicity or withdrawal, surgery, uncontrolled pain, sleep deprivation) — the more predisposing factors present, the smaller a precipitating insult needed to trigger delirium. Delirium is a medical emergency: its presence itself signals a need for prompt evaluation for a potentially life-threatening cause, not just symptom control. It is usually reversible once the precipitating cause is corrected, but unrecognized or poorly managed delirium is associated with prolonged hospitalization and long-term cognitive decline.[2]
Recognize the Condition
Core features
An acute change from the patient's baseline, with a course that fluctuates over the day (lucid intervals are common and do not exclude delirium), inattention (difficulty focusing, sustaining, or shifting attention — often the most sensitive bedside clue), and disorganized thinking or an altered level of consciousness. Symptoms are frequently worse in the evening and overnight ("sundowning").[1]
The 3 delirium subtypes
Hyperactive
Increased psychomotor activity, restlessness, mood lability or agitation, and refusal to cooperate with care. The most easily recognized subtype because it is disruptive and draws staff attention.
Hypoactive
Decreased psychomotor activity, sluggishness or lethargy approaching stupor, and a quiet, withdrawn presentation. This subtype is frequently under-recognized — a quiet, "cooperative" patient is easy to mistake for someone who is simply tired, depressed, or at their cognitive baseline, so hypoactive delirium is missed far more often than hyperactive delirium unless actively screened for with a validated tool rather than relying on staff noticing agitation.
Mixed
Features fluctuate between hyperactive and hypoactive presentations within the same episode, sometimes within the same day.
Risk Factors
Predisposing factors (increase vulnerability)
- Older age.
- Pre-existing cognitive impairment or dementia — the single strongest predisposing factor.
- Sensory impairment (vision or hearing).
- Frailty and multiple comorbidities.
- Prior episode of delirium.
- Functional impairment / poor baseline mobility.
- Admission to a postoperative, palliative care, or intensive care setting.
- Polypharmacy, particularly a high anticholinergic or sedative burden.
- Alcohol use disorder or chronic benzodiazepine use.
Precipitating conditions (trigger the episode)
A useful systematic framework is the "I WATCH DEATH" mnemonic for categories of acute, potentially reversible causes:
| Category | Conditions |
|---|---|
| Infectious | One of the most common causes in older patients — encephalitis, meningitis, pneumonia, soft-tissue infection, urinary tract infection, syphilis. |
| Withdrawal | Alcohol or benzodiazepine withdrawal. |
| Acute metabolic | Acidosis, alkalosis, dehydration, electrolyte disturbance, hypercarbia, liver or kidney failure. |
| Trauma | Heat stroke, burns, recent surgery (prolonged surgeries carry additional risk), pain. |
| CNS pathology | Abscess, hemorrhage, normal pressure hydrocephalus, seizure, stroke, tumor, vasculitis. |
| Hypoxia | Anemia, carbon monoxide poisoning, hypotension, lung or heart failure, pulmonary embolism. |
| Deficiencies | Sensory impairment; vitamin B12, niacin, or thiamine deficiency. |
| Endocrinopathies | Hyper- or hypoglycemia, hyper- or hypoadrenocorticism, hyper- or hypothyroidism, hyper- or hypoparathyroidism. |
| Acute vascular | Arrhythmia, hypertensive encephalopathy or shock, hypotension. |
| Toxins or drugs | One of the most common causes in older patients — general anesthesia, industrial poisons, medications, pesticides, solvents, illicit drugs. |
| Heavy metals | Iron, bromium, lead, manganese, mercury. |
Red Flags & Refer
Any new delirium should prompt urgent evaluation for a life-threatening underlying cause. Escalate immediately for any of the following:
- Signs of sepsis or an unstable infectious source (fever or hypothermia with hemodynamic instability, hypotension, tachycardia out of proportion to baseline).
- Hypoxia (low oxygen saturation) or acute respiratory distress.
- Significant metabolic derangement — severe hypoglycemia, severe hyponatremia, severe hypercalcemia, or marked acid-base disturbance.
- Signs of alcohol or benzodiazepine withdrawal, especially autonomic instability, tremor, or withdrawal seizure — these can progress rapidly and need immediate benzodiazepine treatment, not a "wait and observe" approach.
- New focal neurologic deficit, severe headache, or reduced level of consciousness suggesting stroke, intracranial hemorrhage, or another acute CNS event.
- Severe agitation posing an immediate safety risk to the patient, other patients, or staff, despite verbal de-escalation.
- Hemodynamic instability from any cause.
Assessment & Diagnosis
Delirium vs. dementia vs. depression — the classic diagnostic confusion
Distinguishing delirium from dementia is essential because the treatment implications are entirely different: delirium is an acute emergency requiring urgent cause-finding, while dementia is a chronic process managed on a completely different timeline. Depression is the third common confusable diagnosis, particularly with hypoactive delirium.
| Feature | Delirium | Dementia | Depression |
|---|---|---|---|
| Onset | Acute — hours to days | Insidious — months to years | Subacute — weeks |
| Course over 24 hours | Fluctuates, often worse at night | Relatively stable day to day | Fairly stable, may have diurnal variation |
| Attention | Markedly impaired — the core deficit | Usually preserved until late stages | May be reduced but engageable |
| Level of consciousness | Altered — hyperalert, drowsy, or fluctuating | Normal until very advanced disease | Normal |
| Psychomotor activity | Often abnormal (agitated, slowed, or mixed) | Usually normal early on | Slowed (psychomotor retardation) or normal |
| Hallucinations/delusions | Common, especially visual | Uncommon until advanced stages | Uncommon (unless psychotic features present) |
| Course with treatment | Usually reversible once the cause is treated | Chronic, generally progressive | Treatable but not "acute-onset-and-resolving" |
A patient with pre-existing dementia can develop superimposed delirium — always ask a collateral source (staff, family) whether the current presentation represents an acute change from the patient's own baseline, since "confused" on its own is not informative.
History
- Timeline and course from the patient and, critically, collateral history from staff or family — the single most useful question is whether this represents an acute change from baseline.
- Complete medication review, including over-the-counter products, recent dose changes, and any recently stopped medication (withdrawal).
- Alcohol and substance use history.
- Review of active medical/surgical issues, recent procedures, and pain control.
Examination and investigations
- Full physical examination looking for an infectious source, dehydration, urinary retention or fecal impaction, and new focal neurologic signs.
- Core laboratory work for essentially all patients: complete blood count (including folate and vitamin B12), electrolytes, glucose, renal and liver function, thyroid panel, and urinalysis.
- CT head and/or EEG are not routine — reserve for patients with a new focal neurologic deficit, head trauma, suspected seizure, or another specific clinical suspicion of CNS pathology, rather than ordering them reflexively in every delirious patient.[3]
Screening tools
Use a validated bedside tool consistently, rather than relying on staff noticing agitation, since this is what allows hypoactive delirium to be caught. The Confusion Assessment Method (CAM) is the most widely used — it is a diagnostic algorithm built from 4 features, not a summed severity score.[4]
| CAM feature | What to assess |
|---|---|
| 1. Acute onset and fluctuating course | Is there evidence of an acute change from baseline mental status that fluctuates in severity over the day? |
| 2. Inattention | Does the patient have difficulty focusing attention — for example, being easily distractible or unable to follow a conversation? |
| 3. Disorganized thinking | Is the patient's thinking disorganized or incoherent — rambling, irrelevant conversation, unclear or illogical flow of ideas? |
| 4. Altered level of consciousness | Is the patient anything other than alert — for example, vigilant, lethargic, stuporous, or comatose? |
CAM is positive for delirium (diagnosis met) when Features 1 AND 2 are both present, plus EITHER Feature 3 OR Feature 4. A CAM-ICU version is validated for mechanically ventilated or nonverbal patients.[5] The 4AT is a fast alternative screening tool (alertness, a 4-item cognitive test, an attention test, and acute change/fluctuation) that can be completed in a few minutes without special training and is endorsed alongside CAM by current guidance.[6]
Treatment Targets
- Identify and treat or correct the underlying precipitating cause(s) — this is the actual definitive treatment, not a preliminary step before "real" therapy.
- Maintain the safety of the patient, other patients, and staff by managing agitation with the least restrictive effective approach.
- Prevent delirium-related complications — falls, immobility, aspiration, pressure injury, dehydration, and unnecessary indwelling devices/restraints.
- Support the fastest possible return to the patient's cognitive and functional baseline.
- Minimize cumulative antipsychotic and benzodiazepine exposure — use the lowest effective dose for the shortest duration, and taper/discontinue as soon as delirium resolves.
- Avoid iatrogenic worsening from unaddressed deliriogenic medications, unnecessary restraints, or disrupted sleep-wake cycles.
Choose Initial Treatment
Step 1, always identify and treat the underlying precipitating cause(s) — this is the definitive treatment for delirium; everything else below is supportive management of agitation while the cause is corrected.
Step 2, first-line for all patients non-pharmacologic, multicomponent measures (reorientation, sleep-wake support, early mobilization, sensory aids, avoiding restraints) plus a full medication review to identify and deprescribe deliriogenic drugs. Medications are not routine first-line management of delirium itself.[3]
Step 3, only if non-pharmacologic measures fail and the patient is severely distressed or poses a genuine safety risk to themselves or others a short course of a low-dose antipsychotic (haloperidol, quetiapine, or risperidone) may be used to manage agitation — not to treat delirium itself, since antipsychotics do not reliably shorten delirium duration or severity. Re-evaluate the need for continued therapy daily and discontinue once agitation resolves.[7]
Avoid benzodiazepines for delirium management in general — they can worsen confusion and prolong the episode.
Exception — alcohol or benzodiazepine withdrawal delirium specifically a benzodiazepine (diazepam, or lorazepam/oxazepam if hepatic impairment or older age) is the correct first-line drug therapy for this specific etiology; withholding it here would be the error, not using it.
Non-Pharmacologic Treatment
Multicomponent nonpharmacologic measures — first-line for every patient
- Frequent reorientation — clocks, calendars, and family photos in view, with staff and family reminding the patient of the date, place, and reason for admission at each interaction.
- Ensure the patient has their glasses and hearing aids available and in working order — uncorrected sensory impairment is a major, easily fixed contributor.
- Support the normal sleep-wake cycle: encourage daytime light exposure and activity, minimize nighttime noise/light/unnecessary overnight vitals or medication administration, and avoid daytime napping where possible.
- Mobilize the patient as early and as often as safely possible, rather than defaulting to bed rest.
- Avoid physical restraints — they increase agitation and injury risk and can prolong delirium; use the least-restrictive alternative (1:1 observation, bed/chair alarms, moving the patient closer to the nursing station) instead.
- Communicate the diagnosis to the patient (as appropriate) and caregivers, and actively involve family/caregivers at the bedside — familiar presence is itself therapeutic.
- Maintain hydration, nutrition, and normal bowel/bladder function; treat pain adequately (uncontrolled pain is itself a precipitant).
- Structured multicomponent programs such as the Hospital Elder Life Program (HELP) — targeted screening and interdisciplinary management of predisposing risk factors in older inpatients — reduce delirium incidence and fall rates and are the model this approach is based on.[8]
Medication review and deprescribing — a core pharmacist role
Minimizing or removing drugs that may be contributing to delirium is one of the highest-yield actions a pharmacist can take, and should happen at the same time as, not after, other management steps. Cross-checking the medication list against the current AGS Beers Criteria for potentially inappropriate medications in older adults is a practical way to systematically catch the drug classes below.[9]
| Drug class | Action |
|---|---|
| Anticholinergics (e.g., benztropine, dicyclomine, oxybutynin, scopolamine) | Lower the dose or discontinue if possible. |
| Antidepressants (paroxetine, tricyclic antidepressants) | Consider switching to an SSRI other than paroxetine, or an SNRI. |
| Antiemetics (dimenhydrinate, prochlorperazine, promethazine) | Consider replacing with domperidone, metoclopramide, or a 5-HT3 antagonist (e.g., ondansetron). |
| Antihistamines (brompheniramine, chlorpheniramine, diphenhydramine, doxylamine) | Replace with a second-generation, non-sedating antihistamine. |
| Antipsychotics, especially low-potency first-generation agents | Lower the dose or discontinue if possible; if truly needed for agitation, use a low dose of a high-potency agent instead (see Pharmacologic Treatment Options). |
| Barbiturates | Replace with an alternative or discontinue if possible (weigh seizure risk if the patient has a seizure history). |
| Benzodiazepines and other hypnotics (e.g., zolpidem, zopiclone) | Replace with sleep-hygiene measures. Do not abruptly stop a chronic user — withdrawal itself can precipitate delirium; taper instead. |
| Corticosteroids | Use the lowest effective dose for the shortest duration. |
| H2-receptor blockers (cimetidine, famotidine, ranitidine) | Replace with an antacid or a proton pump inhibitor. |
| Muscle relaxants (cyclobenzaprine, orphenadrine) | Lower the dose or discontinue if possible. |
| Opioids, particularly meperidine | Prefer acetaminophen or an NSAID where adequate for the pain being treated; meperidine specifically should be avoided. Uncontrolled pain is itself a delirium precipitant — do not simply withhold analgesia, weigh the risks and benefits of the specific opioid and dose against undertreated pain. |
There is insufficient evidence to support using any pharmacologic agent — including antipsychotics or melatonin — purely to prevent delirium; multicomponent nonpharmacologic prevention (the HELP model above) is the evidence-based approach to prevention.[10]
Special Populations
Pregnancy
There are no controlled studies of pharmacologic delirium treatment in pregnancy. Use non-pharmacologic measures as first-line management, and reserve pharmacotherapy for situations of significant risk of harm to the patient, fetus, staff, or other patients, with informed consent. Antipsychotic use for psychosis in pregnancy has not been associated with major teratogenic malformations, though prepartum use of a high-potency first-generation agent (e.g., haloperidol) has been associated with neonatal hypertonia.[2]
Breastfeeding
Antipsychotics pass into breast milk at levels generally considered compatible with breastfeeding, though data are limited. If an antipsychotic is used, monitor the infant for lethargy, drowsiness, and (with longer use) developmental milestones. Haloperidol at 10 mg/day or less has not shown adverse infant effects in limited data; higher doses are not recommended. Of the second-generation agents, olanzapine has the most reassuring lactation data; quetiapine also shows low infant exposure; risperidone is associated with relatively more infant exposure and may not be a preferred choice.
Older adults (the population most affected)
Use lower antipsychotic doses than in younger adults (see Pharmacologic Treatment Options for geriatric-specific dosing). Avoid loxapine and olanzapine where possible — both carry significant anticholinergic burden that can worsen cognitive impairment. Avoid benzodiazepines outside the alcohol/benzodiazepine-withdrawal indication; if a benzodiazepine is required for that indication, prefer lorazepam or oxazepam over diazepam given reduced accumulation risk. Older adults, particularly those with pre-existing dementia, carry the FDA boxed-warning mortality and stroke risk with antipsychotic use — weigh this explicitly before starting therapy, use the lowest effective dose, and discontinue promptly once agitation resolves.[11]
Dementia
Delirium superimposed on dementia is common and easily missed if the change from the patient's own baseline is not actively assessed — see Assessment & Diagnosis for the delirium-vs-dementia comparison. The antipsychotic mortality/stroke boxed warning applies specifically to patients with dementia-related psychosis and is directly relevant whenever an antipsychotic is being considered for a delirious patient who also has dementia.
Renal and hepatic impairment
Reduce antipsychotic doses in significant renal or hepatic impairment and monitor closely for accumulation and QTc prolongation. In hepatic impairment, lorazepam or oxazepam are preferred over diazepam for the withdrawal-delirium indication, since they are cleared by glucuronidation without active metabolites.
Pediatrics
Delirium also occurs in children, particularly postoperatively and in the ICU, using pediatric-specific screening tools (e.g., the Cornell Assessment of Pediatric Delirium). Management principles mirror the adult approach — non-pharmacologic measures and treating the underlying cause first — but pediatric antipsychotic dosing for agitated delirium is not well established; involve pediatric specialist input before using an antipsychotic in a child, rather than extrapolating adult doses.
Monitoring & Follow-Up
Reassess delirium status at least daily (more often if agitation is unstable) using the same validated tool (CAM, CAM-ICU, or 4AT) each time, so trajectory — not just a single snapshot — is tracked.[4] If an antipsychotic was started, monitor sedation level, extrapyramidal symptoms, and QTc (baseline and periodically, especially with risk factors: older age, female sex, bradycardia, pre-existing heart disease, hypokalemia, hypomagnesemia) at each reassessment, and confirm daily that continued therapy is still needed. If a benzodiazepine was started for withdrawal delirium, monitor sedation and respiratory status closely, particularly with concurrent CNS depressants. Reassess the medication list again at discharge to confirm any deliriogenic drug that was held is restarted only if truly needed, and that any antipsychotic or benzodiazepine started acutely has actually been stopped rather than carried forward by default. Once delirium resolves, consider a formal cognitive and functional assessment — delirium can unmask previously undetected baseline cognitive impairment that deserves its own follow-up.
Common Errors to Avoid
- Starting an antipsychotic or benzodiazepine as a routine, reflexive response to any delirious patient rather than reserving pharmacotherapy for severe distress or agitation posing a genuine safety risk.
- Missing hypoactive delirium because the patient is quiet and "cooperative" rather than agitated — screen actively with a validated tool instead of relying on staff noticing disruptive behaviour.
- Diagnosing dementia in a patient with an actual acute-onset, fluctuating presentation (or missing delirium superimposed on known dementia) without asking a collateral source about the patient's true baseline.
- Using a benzodiazepine for a delirium etiology other than alcohol/benzodiazepine withdrawal — this typically worsens confusion rather than helping.
- Reaching for physical restraints as a first-line agitation strategy — this increases agitation and injury risk and can prolong the episode.
- Abruptly stopping a chronic benzodiazepine, opioid, or other sedative in a long-term user instead of tapering — precipitates a withdrawal state that itself causes delirium.
- Continuing an antipsychotic started for acute agitation past discharge without a deliberate decision to do so — always taper and discontinue once delirium has resolved.
- Ordering a CT head or EEG reflexively in every delirious patient without a specific clinical indication (new focal deficit, trauma, suspected seizure) rather than reserving it for suspected CNS pathology.
- Starting or continuing a cholinesterase inhibitor (e.g., donepezil) specifically to treat delirium — current evidence does not support benefit for delirium prevention or treatment, so this is not an appropriate use of the drug in this context.
- Overlooking the medication list as a contributing cause — anticholinergic-burden stacking and opioid burden are among the most common, most fixable precipitants a pharmacist will find.
Clinical Decision Algorithm
Drug Tables
How to use this table: Doses are adult doses for managing agitation associated with delirium and require patient-specific confirmation, including renal/hepatic adjustment and reassessment daily. Select any drug name to open its complete Pharmasist Drug Database page.
Antipsychotics, first-generation
Reserved for severe distress or agitation posing a genuine safety risk, after nonpharmacologic measures and cause-directed treatment; not routine.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Haloperidol | Adults: 0.5-1 mg PO/IM q6-12h PRN, max 2 mg/day Older adults: 0.25-0.5 mg PO/IM, max 2 mg/day Children: Not established for routine pediatric use in delirium — specialist-directed only | Sedation, parkinsonism, akathisia, acute dystonia, neuroleptic malignant syndrome, QTc prolongation | Additive CNS depression with other sedatives; avoid combining with other QTc-prolonging drugs | Most-studied agent for agitated delirium. Extrapyramidal symptom risk is dose-related. Small regular doses preferred over PRN-only dosing. Taper and stop once agitation resolves. |
| Loxapine | Adults: 2.5-10 mg PO/IM BID PRN, max 20 mg/day Older adults: Avoid where possible; if used, use the lowest effective dose Children: Not established for routine pediatric use in delirium — specialist-directed only | Sedation, parkinsonism, akathisia, acute dystonia, neuroleptic malignant syndrome, significant anticholinergic effects | Additive CNS depression with other sedatives; avoid combining with other QTc-prolonging drugs | Not recommended in older adults given strong anticholinergic properties that can worsen cognitive impairment. |
Antipsychotics, second-generation
Comparable efficacy to haloperidol in available evidence, with a possibly more favourable adverse-effect profile.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Olanzapine | Adults, oral (incl. orally disintegrating): 2.5-10 mg PO BID PRN, max 20 mg/day Adults, intramuscular: 2.5-10 mg IM; may repeat at 2h and 6h, max 30 mg/24h (max 2.5 mg/dose in debilitated patients) Children: Not established for routine pediatric use in delirium — specialist-directed only | Anticholinergic effects, akathisia/extrapyramidal symptoms, dizziness, neuroleptic malignant syndrome; rare DRESS reaction | Additive sedation with other CNS depressants; avoid combining simultaneously with parenteral benzodiazepines (reports of cardiorespiratory events including death) | Not recommended in older adults given strong anticholinergic properties. Orally disintegrating tablets can help patients unwilling or unable to swallow. |
| Quetiapine | Adults: 12.5-50 mg PO BID PRN, max 100 mg/day Older adults: 12.5-25 mg PO, max 50 mg/day Children: Not established for routine pediatric use in delirium — specialist-directed only | Anticholinergic effects (less than olanzapine/loxapine), akathisia/extrapyramidal symptoms, dizziness, sedation, QTc prolongation | Additive sedation with other CNS depressants | A reasonable alternative when a lower anticholinergic burden or lower extrapyramidal-symptom risk is specifically wanted (e.g., Parkinson disease, Lewy body dementia). |
| Risperidone | Adults: 0.5-1 mg PO BID PRN, max 2 mg/day Older adults: 0.25-0.5 mg PO, max 2 mg/day Children: Not established for routine pediatric use in delirium — specialist-directed only | Anticholinergic effects, akathisia/extrapyramidal symptoms, orthostatic hypotension, QTc prolongation | Additive sedation with other CNS depressants; may potentiate antihypertensive effect | Comparable efficacy to haloperidol with generally fewer anticholinergic effects. |
Benzodiazepines — alcohol or benzodiazepine withdrawal delirium ONLY
Not used for any other delirium etiology; using a benzodiazepine outside this specific indication typically worsens confusion rather than helping.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Diazepam | Adults: Symptom-triggered per a validated withdrawal scale, or a fixed tapering schedule over several days Older adults / hepatic impairment: Avoid — use lorazepam or oxazepam instead | Sedation, ataxia, respiratory depression with other CNS depressants | Additive CNS/respiratory depression with opioids, alcohol, other sedative-hypnotics | Long-acting with active metabolites. Avoid in significant hepatic impairment or older adults — use lorazepam instead. |
| Lorazepam | Adults: Symptom-triggered per a validated withdrawal scale, or a fixed tapering schedule over several days Preferred population: Hepatic impairment or older adults | Sedation, ataxia, respiratory depression with other CNS depressants | Additive CNS/respiratory depression with opioids, alcohol, other sedative-hypnotics | No active metabolites — cleared by glucuronidation only, giving more predictable clearance in hepatic impairment and older age. |
Supportive / adjunctive therapy
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Thiamine | Adults, at-risk/empiric: Per institutional Wernicke-prophylaxis protocol Older adults, alcohol-related: A commonly used protocol is 200 mg parenteral thiamine IM or IV daily for 3-5 days | Rare injection-site reaction with parenteral administration; otherwise well tolerated | None significant | Give empirically before or with glucose in any patient with suspected thiamine deficiency (malnutrition, alcohol use disorder) to prevent precipitating or worsening Wernicke encephalopathy. |
| Acetaminophen | Adults: Per standard analgesic dosing, not to exceed the maximum daily dose | Hepatotoxicity in overdose; generally well tolerated at recommended doses | Caution with other hepatotoxic drugs; significant chronic alcohol use increases hepatotoxicity risk | Preferred first-line analgesic for pain that may be contributing to delirium, in preference to an opioid (particularly meperidine) where adequate for the pain being treated. |
Agents without sufficient evidence for routine use
Included here for completeness — none of the following should be started outside a specialist-directed or ICU-specific context; evidence does not currently support routine use for delirium prevention or treatment.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Dexmedetomidine | ICU, specialist-directed: Per institutional ICU sedation protocol | Hypotension, bradycardia, sedation | Additive bradycardia/hypotension with other sedatives or antihypertensives | An ICU-specific sedative that may be considered for a mechanically ventilated, agitated-delirious patient unable to wean from the ventilator; evidence for delirium-specific benefit is still evolving and it is not a general-ward option. |
| Melatonin | If used: Per standard over-the-counter dosing | Generally well tolerated; daytime drowsiness | Caution with other sedatives | Proposed for delirium prevention based on limited evidence; not established as effective, and not a substitute for nonpharmacologic prevention measures. |
| Ketamine | Dosing: Not established for delirium — do not use outside a specialist-directed protocol | Dissociative effects, hypertension, tachycardia, emergence reactions | Additive CNS effects with other sedatives | Role in delirium-associated agitation is under investigation; insufficient evidence exists to support any specific dosing recommendation outside an investigational or specialist-directed protocol. |
References
- Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR) — American Psychiatric Association. American Psychiatric Publishing, 2022
- American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults — Journal of the American Geriatrics Society (American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults). J Am Geriatr Soc 2015;63(1):142-150
- Delirium: prevention, diagnosis and management in hospital and long-term care — National Institute for Health and Care Excellence. NICE Clinical Guideline CG103, updated 18 January 2023
- Clarifying confusion: the confusion assessment method. A new method for detection of delirium — Annals of Internal Medicine (Inouye SK, van Dyck CH, Alessi CA, et al.). Ann Intern Med 1990;113(12):941-948
- Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU — Critical Care Medicine (Devlin JW, Skrobik Y, Gélinas C, et al.). Crit Care Med 2018;46(9):e825-e873
- Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people — Age and Ageing (Bellelli G, Morandi A, Davis DH, et al.). Age Ageing 2014;43(4):496-502
- Antipsychotics for treatment of delirium in hospitalised non-ICU patients — Cochrane Database of Systematic Reviews (Burry L, Mehta S, Perreault MM, et al.). Cochrane Database Syst Rev 2018;6:CD005594
- A multicomponent intervention to prevent delirium in hospitalized older patients — New England Journal of Medicine (Inouye SK, Bogardus ST Jr, Charpentier PA, et al.). N Engl J Med 1999;340(9):669-676
- American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults — Journal of the American Geriatrics Society (American Geriatrics Society Beers Criteria Update Expert Panel). J Am Geriatr Soc 2023;71(7):2052-2081
- Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients — Cochrane Database of Systematic Reviews (Burton JK, Craig LE, Yong SQ, et al.). Cochrane Database Syst Rev 2021;7(7):CD013307
- Antipsychotics, other psychotropics, and the risk of death in patients with dementia: number needed to harm — JAMA Psychiatry (Maust DT, Kim HM, Seyfried LS, et al.). JAMA Psychiatry 2015;72(5):438-445
Professional reference only. Apply clinical judgment and verify patient-specific decisions against current authoritative guidance and product information.