Managing delirium

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Delirium is now recognised as a presenting feature of COVID-19. 

In the presence of delirium and/or dementia, patients may not be able to accurately report symptoms.

In such patients, do not rely on the absence of typical symptoms alone to exclude COVID-19.

Delirium is common in COVID-19, especially in older patients in whom there is around a 30% prevalence (60% with comorbid dementia).

Please see here for more detailed guidance from the British Geriatrics Society, the European Delirium Association and the Royal College of Psychiatrists.

  • Due to the ease of transmission of COVID-19, the risk of harm to others may exceed risk of harm to the individual and this may necessitate earlier use of pharmacological treatment for potentially risky behaviour.
  • In some patients mittens may be necessary to enable oxygen to be delivered.

Reducing the risk of delirium

Patients with COVID-19 at high risk of delirium (older age, dementia) should have the following risk factors addressed:

  1. dehydration,
  2. constipation,
  3. visual and hearing impairment (provide usual aids),
  4. hypoxia,
  5. disorientation (provide frequent reassurance and explanation).

Detection and general assessment

  • Proactively identify (using  4AT) in all suspected or confirmed cases of COVID-19.
  • Document  the diagnosis
  • Be aware of the risk of alcohol withdrawal syndrome and other drug withdrawal syndromes (antidepressants, benzodiazepines, gabapentin, pregabalin)
  • Initiate TIME bundle

Distress and behavioural change

  • Assess the patient for potential distress and behavioural change.
  • Assess for modifiable triggers such as pain, urinary retention, constipation, hypoxia, and psychosis.
  • Provide repeated reassurance and explanation verbally and if possible through phone or video contact with family members. Complete Getting to Know Me
  • If non-pharmacological  interventions do not resolve distress or restlessness, consider drug interventions.

Drug interventions if non-pharmacological  interventions do not resolve distress or restlessness

Medication

Single starting dose

Maximum dose in 24 hours*

Cautions/Contraindications

Haloperidol**

0.5mg orally

0.5mg IM

2mg orally

2mg IM

Prolonged QTc interval in ECG.

Signs of parkinsonism or lewy body dementia.

When used with any medication that prolongs QT interval this is off-license.

Risperidone

0.25mg orally

1mg in divided doses

Signs of parkinsonism or lewy body dementia.

Not licensed in delirium.

Lorazepam if antipsychotics are contraindicated

0.5mg orally

0.5mg-1mg IM

2mg orally

2mg IM

Caution in renal impairment.

Not licensed in delirium.

*unless on the specific advice of a specialist, e.g. mental health liaison.

**note the BNF max dose for haloperidol is 5mg in 24 hrs, but we would suggest a more conservative approach with max 2mg in 24 hours in the first instance. Where higher dosages are required please seek specialist advice.

 Doses may need to be repeated but use caution because of the risk of over-sedation and respiratory depression. Additionally, if haloperidol is ineffective then lorazepam can be used.