Prompt treatment of the underlying medical condition is
essential, along with correction of any remediable pre-
disposing factors and elimination of all drugs that might
cause delirium. Symptoms usually remit following resolution
of the underlying cause.
Supportive measures designed to calm, reassure, and protect
the patient are also important. It is helpful to "normalize" the
environment by having family members present and placing a
clock, a calendar, and familiar objects in the room.
Alterations in activity schedules and lighting can help restore
a normal sleep cycle. The main room lights should be dimmed
at night, but a night-light should be left on so the patient can
reorient if he or she awakes in darkness. Daytime exposure to
natural lighting through a window may also be helpful (7).
Supportive therapy should aim to calm anxiety or agitation and
ensure protection from harm for the patient and others. The
patient may be at risk because of suicidal ideation, confusion, or
psychosis, so it is helpful for the physician to exhibit a calm,
reassuring manner. Use of physical restraints may occasionally
be necessary for the patient's protection. However, this may
further agitate some patients. Restraints should be used only
when less intrusive measures have been inadequate.
Psychotropic medications are prescribed if necessary to treat
significant anxiety, agitation, or psychosis (8). The most useful
medications for anxious or agitated patients are short-acting
benzodiazepines, such as lorazepam (Ativan) and oxazepam
(Serax). High-potency antipsychotic agents such as haloperidol
(Haldol), which can be administered orally, intramuscularly, or
intravenously, can be given to patients with psychotic symptoms.
With all of these agents, doses must be individualized, but a
small amount of medication often suffices. The need for such
drugs usually abates when the delirium resolves.
Pharmaceuticals with a high degree of anticholinergic effect,
such as chlorpromazine hydrochloride (Ormazine, Thorazine),
may exacerbate confusion and should be avoided. Patients with
preexisting psychiatric disorders (eg, schizophrenia) sometimes
present special treatment challenges and may require psychiatric
Treatment of patients whose delirium stems from alcohol or
sedative-hypnotic withdrawal merits special consideration (9).
Mild withdrawal states are generally self-limiting, requiring only
supportive care for the patient. Multivitamins, thiamine hydrochloride
(Biamine), and magnesium are often useful.
However, when patients have irritability and autonomic signs
along with confusion and perceptual distortions, more aggressive
treatment is required, usually therapy with a cross-tolerant sedative
-hypnotic and supportive measures. Benzodiazepines are appropriate
in most cases, but views about the best choice of pharmacotherapy
differ. Once a choice is made, dosage is adjusted to provide
coverage for withdrawal symptoms, then gradually decreased.
The exact withdrawal schedule depends on the particular clinical
situation, including the patient's degree of dependence and overa
medical and psychological state.
Although withdrawal over a few days is appropriate for many patients,
others require prolonged tapering to prevent the reemergence of
significant withdrawal symptoms. Severe alcohol or sedative-hypnotic
withdrawal can be complicated by life-threatening fever, autonomic
dysregulation, and seizures, which require aggressive management.
Fortunately, the great majority of patients experience mild syndromes.