Management of Acutely Disturbed Patients, including Delirium

Pharmacological management

This should only be used when non-pharmacological management is unsuccessful and symptoms are causing significant distress to the patient, or symptoms threaten the safety of the patient or others (including their ability to accept necessary medical or nursing care).

Important points to note:

• Be aware that sedative medication is associated with significant risks including increased risk of aspiration and falls.
• Always use the oral route whenever possible.
• Start at the lowest clinically appropriate dose, titrate cautiously according to symptoms and review at least every 24 hours.
• Emergency sedation can be given under common law, more routine sedation however requires consideration of the patient’s capacity to consent.
• If patient is unable to give consent (which is likely) then section 47 of the Adults with Incapacity (Scotland) Act 2000 must be used (see Appendix 4 for details). Always document in medical case record reasons for prescribing sedation, indicating review dates.
• If patient is attempting to leave the hospital or requiring physical or chemical restraint then detention under the Mental Health act may be required (see Appendix 4 for more details). 

Outwith the emergency situation it is very important that the patient, or more usually the Power of Attorney or next of kin, is made aware of the potential risks described above and agrees that the treatment is of benefit to the patient, is the least restrictive option and the benefit outweighs the risk. This discussion should be recorded as part of the treatment plan attached to the Section 47 form.

Before prescribing read all the information above and below for cautions, contraindications and dose administration advice (take into account frailty when considering total daily dose). Ensure patients are closely monitored following administration of sedative medication. Emergency sedation should always be discussed with a registrar or consultant.

Antipsychotic medication

• Different antipsychotic medications should never be given in combination unless under specialist psychiatry advice.
• Be aware that antipsychotic medication can cause Neuroleptic Malignant Syndrome (NMS) and acute dystonic reactions. NMS is a life-threatening neurological emergency characterised by high fever, confusion, rigidity, labile BP, sweating and tachycardia. If any of these signs develop, seek senior help immediately.
• Do not give antipsychotic medication to patients with Parkinsonism or Lewy body dementia; consult guidance under benzodiazepine section below for these patients.

Haloperidol

Stop and check as haloperidol is contraindicated in the following situations:

• Prolonged QTc interval
• In combination with other drugs that prolong the QTc interval
• In patients with Parkinson's disease, Lewy body dementia, progressive supranuclear palsy (PSP) and multiple system atrophy (MSA).

Prior to treatment (or as soon as possible afterwards if the patient is too agitated) record an ECG to check QT interval. Ensure modifiable risk factors for QTc prolongation are minimised e.g. electrolyte abnormalities (hypokalaemia, hypomagnesaemia, hypocalcaemia) and discontinue other drugs known to prolong QTc if possible. A list of drugs that can prolong QT interval can be found at http://crediblemeds.org. Further information can also be found in the Medicines Update Extra (MUE 08) drug induced prolongation article available at www.ggcmedicines.org.uk. 

Start with the lowest clinically appropriate dose and titrate according to symptoms. Use the lower dose range in frail or elderly patients. Always use oral medication wherever possible and wait a minimum of 1 hour before repeat dosing. 

• Haloperidol oral 500micrograms –1mg (maximum 2mg in 24 hours) or, only if oral route is not possible:
• Haloperidol IM 500micrograms (maximum 2mg in 24 hours)

If haloperidol is contraindicated because the patient is already on drugs that can prolong the QT interval which cannot be stopped, consider risperidone but be aware that caution is still required and an ECG should be recorded and monitored during treatment. 

• Risperidone oral 250-500micrograms (up to a maximum of 2mg in 24 hours). Use the lower dose range in frail or elderly patients.

Benzodiazepines

If antipsychotic medication is contraindicated e.g. in Parkinson's disease, MSA, PSP or Lewy body dementia, consider benzodiazepines and contact the local movement disorder team as soon as possible for further advice. Use with caution in patients with respiratory impairment and be aware that benzodiazepines can have a paradoxical effect in delirium. If the patient does not improve or the disturbed behaviour gets worse, discuss with a senior or seek specialist advice before giving any further doses.

• Lorazepam oral 500micrograms –1mg (maximum 2mg in 24 hours)* (use the lower dose range in frail or elderly patients) or only in exceptional circumstances if oral route not possible:
• Midazolam IM 2mg (maximum 6mg in 24 hours)*

*Wait a minimum of 1 hour between doses and ensure that IV flumazenil is available in case of benzodiazepine induced respiratory depression. 

Monitoring

After administration of sedative medication, monitor observations and conscious level and check for side effects. If there is any deterioration seek senior help immediately. Once the acute situation has been stabilised, perform a thorough clinical assessment to ensure all potential underlying causes of delirium and acutely disturbed behaviour have been addressed. Ensure you handover to the patient's regular team if sedation is prescribed out of hours to ensure early review and follow-up.

The above is a guide to initial management. If these measures do not result in an improvement in the disturbed behaviour, speak to senior medical staff to discuss alternatives. Other drug options are available and specialist advice from psychiatry may be required.