An 83-year-old woman is sent to the emergency department from the nursing home where she resides for evaluation of mental status changes. At baseline, she has mild memory impairment but is otherwise cognitively intact, calm, and cooperative with the nursing home staff. Over the past 24 hours, she has become increasingly combative and agitated and stayed up all night. Behavioral interventions and environmental modifications have not been helpful. The patient's medical conditions include hypertension and a history of anxiety and depression. Temperature is 37.2 C (99 F), blood pressure is 110/80 mm Hg, pulse is 84/min, and respirations are 18/min. Neurological examination is normal, but the patient is unable to attend to the conversation, is mildly disoriented, and cannot state the days of the week backwards. Without provocation, she strikes out at a nurse's aide standing next to her. Laboratory results are normal except for urinalysis, which shows an increased presence of white blood cells and is positive for nitrites. Head CT scan is negative. In addition to starting antibiotic therapy, which of the following medications is most appropriate to treat this patient's behavioral symptoms?
Delirium is an acute-onset "confusional state" characterized primarily by waxing and waning mental status changes and impaired attention. Disorientation, agitation, psychosis, and sleep disturbances may also occur. Delirium occurs secondary to an underlying medical condition, such as a urinary tract infection, and therefore the primary management is treating the underlying cause. The elderly and those with preexisting cognitive disorders are at a higher risk for delirium and may present with varying degrees of agitation.
High-potency, first-generation antipsychotics (eg, haloperidol) and some second-generation antipsychotics (eg, quetiapine) can be used for the acute treatment of agitation and psychosis associated with delirium. Antipsychotic use is appropriate in the treatment of delirium in the elderly if the patient is at risk of acute harm to self or others and behavioral interventions have failed. Under these conditions, the benefits of antipsychotics (ie, the provision of safety) outweigh the potential risks when used at low doses and short durations.
(Choice A) Clozapine is a second-generation antipsychotic that is reserved for patients with treatment-refractory schizophrenia. It is not used for the short-term treatment of agitation in delirium due to the risk of agranulocytosis.
(Choice B) Doxepin is a tricyclic antidepressant with anticholinergic effects that can worsen delirium. It may be used for the treatment of insomnia in other settings.
(Choice D) Lithium is a mood stabilizer. It is not used for the short-term treatment of behavioral dyscontrol in nonmanic patients.
(Choices E and F) Benzodiazepines (eg, lorazepam, temazepam) can worsen confusional states, particularly in the elderly. Benzodiazepines are appropriate only for the treatment of delirium due to alcohol or benzodiazepine withdrawal.
Educational objective:
Delirium may manifest as acute changes in cognition and behavior. When nonpharmacological interventions are ineffective, low-dose antipsychotics (eg, haloperidol) are the medications of choice to treat the behavioral (eg, severe agitation) and psychotic manifestations of delirium.