PRACTICE GUIDELINE FOR THE Treatment Of Patients With Delirium
PRA CT ICE GU IDEL INE FO R TH ETreatment of Patients WithDeliriumWORK GROUP ON DELIRIUMPaula Trzepacz, M.D., ChairWilliam Breitbart, M.D.John Franklin, M.D.James Levenson, M.D.D. Richard Martini, M.D.Philip Wang, M.D., Dr.P.H. (Consultant)Originally published in May 1999. This guideline is more than 5 years old and has not yetbeen updated to ensure that it reflects current knowledge and practice. In accordance withnational standards, including those of the Agency for Healthcare Research and Quality’sNational Guideline Clearinghouse (http://www.guideline.gov/), this guideline can no longerbe assumed to be current. The August 2004 Guideline Watch associated with this guidelineprovides Additional information that has become available since publication of the guideline,but it is not a formal update of the guideline.1Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyrightprotections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permissionfor reuse, visit APPI Permissions & Licensing Center at ons.aspx.
AMERICAN PSYCHIATRIC ASSOCIATIONSTEERING COMMITTEE ON PRACTICE GUIDELINESJohn S. McIntyre, M.D.,ChairSara C. Charles, M.D.,Vice-ChairDaniel J. Anzia, M.D.Ian A. Cook, M.D.Molly T. Finnerty, M.D.Bradley R. Johnson, M.D.James E. Nininger, M.D.Paul Summergrad, M.D.Sherwyn M. Woods, M.D., Ph.D.Joel Yager, M.D.AREA AND COMPONENT LIAISONSRobert Pyles, M.D. (Area I)C. Deborah Cross, M.D. (Area II)Roger Peele, M.D. (Area III)Daniel J. Anzia, M.D. (Area IV)John P. D. Shemo, M.D. (Area V)Lawrence Lurie, M.D. (Area VI)R. Dale Walker, M.D. (Area VII)Mary Ann Barnovitz, M.D.Sheila Hafter Gray, M.D.Sunil Saxena, M.D.Tina Tonnu, M.D.STAFFRobert Kunkle, M.A., Senior Program ManagerAmy B. Albert, B.A., Assistant Project ManagerLaura J. Fochtmann, M.D., Medical EditorClaudia Hart, Director, Department of Quality Improvement andPsychiatric ServicesDarrel A. Regier, M.D., M.P.H., Director, Division of Research2APA Practice GuidelinesCopyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyrightprotections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permissionfor reuse, visit APPI Permissions & Licensing Center at ons.aspx.
CONTENTSStatement of Intent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Development Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7I. Summary of Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9A. Coding System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9B. General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9II. Disease Definition, Epidemiology, and Natural History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10A. Definition and Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10B. Associated Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12C. Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12D. Prevalence and Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12E. Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13F. Use of Formal Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15III. Treatment Principles and Alternatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17A. Psychiatric Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17B. Environmental and Supportive Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20C. Somatic Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22IV. Formulation and Implementation of a Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27A. Psychiatric Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27B. Choice of Specific Environmental and Supportive Interventions. . . . . . . . . . . . . . . . . . . . . . 28C. Choice of Somatic Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28D. Issues of Competency and Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29V. Clinical Features Influencing Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30A. Comorbid Psychiatric Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30B. Comorbid General Medical Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30C. Advanced Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30VI. Reviewers and Reviewing Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31VII. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Treatment of Patients With Delirium3Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyrightprotections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permissionfor reuse, visit APPI Permissions & Licensing Center at ons.aspx.
Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyrightprotections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permissionfor reuse, visit APPI Permissions & Licensing Center at ons.aspx.
STATEMENT OF INTENTThe American Psychiatric Association (APA) Practice Guidelines are not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined onthe basis of all clinical data available for an individual patient and are subject to change as scientific knowledge and technology advance and practice patterns evolve. These parameters ofpractice should be considered guidelines only. Adherence to them will not ensure a successfuloutcome for every individual, nor should they be interpreted as including all proper methodsof care or excluding other acceptable methods of care aimed at the same results. The ultimatejudgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatmentoptions available.This practice guideline has been developed by psychiatrists who are in active clinical practice. In addition, some contributors are primarily involved in research or other academicendeavors. It is possible that through such activities some contributors, including work groupmembers and reviewers, have received income related to treatments discussed in this guideline. A number of mechanisms are in place to minimize the potential for producing biasedrecommendations due to conflicts of interest. Work group members are selected on the basisof their expertise and integrity. Any work group member or reviewer who has a potential conflict of interest that may bias (or appear to bias) his or her work is asked to disclose this to theSteering Committee on Practice Guidelines and the work group. Iterative guideline drafts arereviewed by the Steering Committee, other experts, allied organizations, APA members, andthe APA Assembly and Board of Trustees; substantial revisions address or integrate the comments of these multiple reviewers. The development of the APA practice guidelines is notfinancially supported by any commercial organization.More detail about mechanisms in place to minimize bias is provided in a document available from the APA Department of Quality Improvement and Psychiatric Services, “APAGuideline Development Process.”This practice guideline was approved in December 1998 and published in May 1999.Treatment of Patients With Delirium5Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyrightprotections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permissionfor reuse, visit APPI Permissions & Licensing Center at ons.aspx.
INTRODUCTIONThis practice guideline seeks to summarize data regarding the care of patients with delirium. Itbegins at the point where the psychiatrist has diagnosed a patient as suffering from deliriumaccording to the DSM-IV criteria for the disorder. The purpose of this guideline is to assist thepsychiatrist in caring for a patient with delirium.Psychiatrists care for patients with delirium in many different settings and serve a variety offunctions. In many cases, a psychiatrist will serve as a consultant to the attending physician andwill not have primary responsibility for the patient. This guideline reviews the treatment thatpatients with delirium may need. The psychiatrist should either provide or advocate for the appropriate treatments. In addition, many patients have comorbid conditions that cannot be described completely with one DSM diagnostic category. Therefore, the psychiatrist caring forpatients with delirium should consider, but not be limited to, the treatments recommended inthis practice guideline.To share feedback on this or other published APA practice guidelines, a form is available athttp://www.psych.org/psych pract/pg/reviewform.cfm.6APA Practice GuidelinesCopyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyrightprotections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permissionfor reuse, visit APPI Permissions & Licensing Center at ons.aspx.
DEVELOPMENT PROCESSThis practice guideline was developed under the auspices of the Steering Committee on Practice Guidelines. The process is detailed in a document available from the APA Department ofQuality Improvement and Psychiatric Services: the “APA Guideline Development Process.”Key features of the process include the following: a comprehensive literature review (description follows) and development of evidencetables; initial drafting by a work group that included psychiatrists with clinical and researchexpertise in delirium; the production of multiple drafts with widespread review, in which 12 organizations andover 83 individuals submitted comments (see Section VI); approval by the APA Assembly and Board of Trustees; and planned revisions at 3- to 5-year intervals.A computerized search of the relevant literature from MEDLINE, PsycINFO, and EMBASEwas conducted.The first literature search was conducted by searching MEDLINE, using PubMed, for theperiod 1966 to April 1996 and used the keywords “organic mental disorders,” “psychotic,”“delirium,” “delusions,” “acute organic brain syndrome,” “alcohol amnestic disorder,” “psychoses,” “substance-induced,” and “intensive care psychosis” with “haloperidol,” “droperidol,” “antipsychotic agents,” “physostigmine,” “tacrine,” “cholinergic agents,” “benzodiazepines,” “thiamine,”“folic acid,” “vitamin b 12,” “vitamins,” “morphine,” “paralysis,” “electroconvulsive therapy,”“risperidone,” and “neuroleptic malignant syndrome.” A total of 954 citations were found.A second search in MEDLINE was completed for the period 1995 to 1998 and used the keywords “delirium,” “dementia,” “amnestic,” “cognitive disorders,” and “delusions” with “haloperidol,” “droperidol,” “antipsychotic agents,” “physostigmine,” “tacrine,” “cholinergic agents,”“benzodiazepines,” “vitamins,” “morphine,” “paralysis,” “electroconvulsive therapy,” “risperidone,”and “neuroleptic malignant syndrome.” A total of 1,386 citations were found.The literature search conducted by using PsycINFO covered the period 1967 to November1998 and used the key words “delirium” and “treatment & prevention” with “psychosocial,”“behavioral,” “restraint,” “seclusion,” “isolation,” “structure,” “support,” “sensory deprivation,”“orient,” “reorient,” and “delirium tremens.” A total of 337 citations were found.An additional literature search was conducted by using EMBASE for the period 1985 toNovember 1998 and used the key word “delirium” with “vitamins,” “morphine,” “paralysis,”“electroconvulsive therapy,” and “neuroleptic malignant syndrome.” A total of 156 citationswere found.Treatment of Patients With Delirium7Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyrightprotections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permissionfor reuse, visit APPI Permissions & Licensing Center at ons.aspx.
Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyrightprotections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permissionfor reuse, visit APPI Permissions & Licensing Center at ons.aspx.
I. SUMMARY OF RECOMMENDATIONSThe following executive summary is intended to provide an overview of the organization andscope of recommendations in this practice guideline. The treatment of patients with deliriumrequires the consideration of many factors and cannot be adequately reviewed in a brief summary. The reader is encouraged to consult the relevant portions of the guideline when specifictreatment recommendations are sought. This summary is not intended to stand on its own.왘A. CODING SYSTEMEach recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories representvarying levels of clinical confidence regarding the recommendations:[I] Recommended with substantial clinical confidence.[II] Recommended with moderate clinical confidence.[III] May be recommended on the basis of individual circumstances.왘B. GENERAL CONSIDERATIONSDelirium is primarily a disturbance of consciousness, attention, cognition, and perception butcan also affect sleep, psychomotor activity, and emotions. It is a common psychiatric illnessamong medically compromised patients and may be a harbinger of significant morbidity andmortality. The treatment of patients with delirium begins with an essential array of psychiatricmanagement tasks designed to provide immediate interventions for urgent general medicalconditions, identify and treat the etiology of the delirium, ensure safety, and improve the patient’s functioning. Environmental and supportive interventions are also generally offered to allpatients with delirium and are designed to reduce factors that may exacerbate delirium, to reorient patients, and to provide them with support. Somatic interventions largely consist ofpharmacologic treatment with high-potency antipsychotic medications. Other somatic interventions may be of help in particular cases of delirium due to specific etiologies or with particular clinical features.1. Psychiatric managementPsychiatric management is an essential feature of treatment for delirium and should be implemented for all patients with delirium [I]. The specific tasks that constitute psychiatric management include the following: coordinating the care of the patient with other clinicians; identifyingthe underlying cause(s) of the delirium; initiating immediate interventions for urgent generalmedical conditions; providing treatments that address the underlying etiology of the delirium;assessing and ensuring the safety of the patient and others; assessing the patient’s psychiatric statusand monitoring it on an ongoing basis; assessing individual and family psychological and socialcharacteristics; establishing and maintaining a supportive therapeutic stance with the patient,the family, and other clinicians; educating the patient, family, and other clinicians regarding theillness; and providing postdelirium management to support the patient and family and providing education regarding risk factors for future episodes.2. Environmental and supportive interventionsThese interventions are generally recommended for all patients with delirium [I]. Environmentalinterventions are designed to reduce or eliminate environmental factors that exacerbate delirium.Treatment of Patients With Delirium9Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyrightprotections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permissionfor reuse, visit APPI Permissions & Licensing Center at ons.aspx.
They include providing an optimal level of environmental stimulation, reducing sensory impairments, making environments more familiar, and providing environmental cues that facilitate orientation. Cognitive-emotional supportive measures include providing patients withreorientation, reassurance, and information concerning delirium that may reduce fear or demoralization. In addition to providing such supportive interventions themselves, it may behelpful for psychiatrists to inform nursing staff, general medical physicians, and family members of their importance.3. Somatic interventionsThe choice of somatic interventions for delirium will depend on the specific features of a patient’s clinical condition, the underlying etiology of the delirium, and any associated comorbidconditions [I]. Antipsychotic medications are often the pharmacologic treatment of choice [I].Haloperidol is most frequently used because it has few anticholinergic side effects, few active metabolites, and a relatively small likelihood of causing sedation and hypotension. Haloperidolmay be administered orally, intramuscularly, or intrav
6 APA Practice Guidelines INTRODUCTION This practice guideline seeks to summarize data regarding the care of patients with delirium. It begins at the point where the psychiatrist has diagnosed a patient as suffering from delirium according to the DSM-IV criteria for the disorder. The purpose of this guideline is to assist the
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