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Canterbury DHB

Management

• It is vital to explain to the patient and family the nature of the problem and all that is being undertaken.
• Minimise staff changes and encourage the presence of family members where possible. Ensure a calm environment with frequent re-orientating measures.
• Investigate and treat underlying cause(s).
• Remove or reduce drugs with known CNS effects if clinically appropriate.
• Oxygen may help if patient is cyanosed.
• High dose dexamethasone (e.g. 16 mg stat) if cerebral tumour.
• Sedation with benzodiazepines should be avoided initially as they can exacerbate the condition.
• If the patient is symptomatic (nocturnal confusion, agitation, aggression, hallucinations, paranoia etc) and where there are no immediately reversible causes the best treatment is HALOPERIDOL:
  • Haloperidol 0.5 mg - 1 mg subcut stat and repeat after 30 minutes if necessary - this dose can then be doubled after a further 30 minutes if no improvement.
  • Large doses may be required (10-20 mg/24 hours subcut) to achieve a response.
  • Aim for a regular BD dose or a continuous subcut infusion.
  • The combination of haloperidol and clonazepam (or midazolam) is generally needed in the management of intractable delirium in the dying patient.

Note: In severe or complicated cases, an urgent referral to either the Psychiatric Consult or Palliative Care Service is recommended.

Topic Code: 4143