Delirium

As a second-year resident, I spend weeks on night-float rotations, acting as the cross-cover physician for general medicine patients. Without fail, my nights will be peppered with pages about acutely delirious patients. Communications range the spectrum from “Patient oriented × 1” and “Patient pulled out Foley cath” to “Patient trying to leave hospital, thinks nurses are poisoning him.” Hardly a surprise, given the estimated 20% of hospital inpatients who have delirium.

Pages from nursing staff often come with a request for an order, and I wish a I had “quick fix” medication I could send off. Unfortunately, our choices of drug our fraught. In their recently published systematic review in Annals, Nikooie and colleagues (1) found no evidence for antipsychotics versus placebo on many different outcome measures, including sedation status, hospital length of stay, and mortality. Harms included QT prolongation with antipsychotics, and many of the studies excluded patients with cardiac and neurologic issues. As the authors point out, there is no FDA-approved medication for delirium, and it can be a challenge to even identify and study this disease state.

Each page carries with it a difficult choice, particularly for patients who are acutely agitated. Nursing staff is often frustrated and concerned, spending much of the night working to keep the patient safe. Nonpharmacologic preventive strategies could be discussed by the day team but are less helpful at 2 a.m. One-on-one sitters who can gently reorient and redirect the patient are often in short supply in the middle of the night. We want to address the underlying cause, but diagnostic uncertainty always exists. We wonder: Is this patient delirious from too many pain medications or from undertreated pain? Sleep deprivation or sleep medication? Is this all from the pneumonia, or are we missing something? We want to provide reassurance, yet we know delirium is associated with numerous adverse outcomes. My last call shift, I called our operations administrator overnight to secure staffing for a sitter, emphasizing the true patient safety need for a delirious patient. It took more effort than writing an order for haloperidol, but it was better for the patient. I cannot apply a broad-based, one-size-fits-all approach to delirium, but I can communicate that I am taking delirium seriously, even if I do not have a specific medication to offer.

Reference

1. Nikooie R, Neufeld KJ, Oh ES, et al. Antipsychotics for treating delirium in hospitalized adults: a systematic review. Ann Intern Med. 2019;171:485-95. [PMID: 31476770] doi:10.7326/M19-1860