Dementia

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1. Dementia is the most common disorder that must be distinguished from delirium.

2. The major difference between dementia and delirium is that demented patients are alert without the disturbance of consciousness characteristic of delirious patients.

3. Information from family or caretakers is helpful in determining whether there was a pre-existing dementia.

B. Psychotic Disorders and Mood Disorders with Psychotic Features. Delirium can be distinguished from other conditions with psychotic symptoms by the abrupt development of cognitive deficits including disturbance of consciousness. In delirium, there should be some evidence of an underlying medical or substance-related condition.

C. Malingering. Patients with malingering lack objective evidence of a medical or substance-related condition.

V. Treatment of Delirium

A. Most cases of delirium are treated by correcting the underlying condition.

B. Delirious patients represent major management problems due to agitation, confusion, and perceptual disturbances. Haloperidol (Haldol), 1-2 mg given every 4-8 hours, is the only antipsychotic available in IV form. Intravenous administration may be necessary in medically ill patients. Haloperidol may also be given IM.

C. None of the atypical antipsychotics are available in parenteral form. If patients are willing to take oral medication, small doses of highly sedating, low-potency medication like quetiapine (Seroquel) 25 mg every 4-8 hours can be very effective. Careful monitoring of heart rate and blood pressure is necessary in patients receiving more than two doses per day.

D. Agitation can also be treated with lorazepam (Ativan) 1-2 mg every 2-6 hours PO, IM or IV. Lorazepam is safe in the elderly and those patients with compromised renal or hepatic function. It should be used cautiously in patients with respiratory dysfunction. It may cause increased confusion.

E. A quiet environment with close observation should be provided. Physical restraints may be necessary to prevent injury to self or others.

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