- Treat any potentially reversible cause(s), if appropriate
- Optimise pain control
- Non-pharmacological management
- Drug treatment
Non-pharmacological measures
- Frequent reorientation
- Providing a calm environment that avoids both sensory deprivation and overstimulation
- Using clear verbal instructions
- Providing emotional support
- Avoiding confrontation
- Do not confront delusional beliefs
- Focus on emotions not content
- Promote a normal sleep-wake cycle
- Correct sensory deficits
- Minimize physical restraints
- Consider discontinuing or avoiding intravenous or urinary catheters
- Minimize room and staff changes
- Request that family members bring in familiar items and sit with the patient
Pharmacological measures
| Drug |
Suggested oral dose |
| Haloperidol (oral) |
Start with 0.5mg at bedtime and q2h p.r.n.
If necessary, increase dose progressively (e.g. → 1.0mg → 1.5mg etc). The maintenance dose is based on initial cumulative dose needed to settle the patient. Usual max is 5mg/24h. |
| Risperidone |
Start with 0.5mg b.d. and p.r.n.
If necessary, increase by 0.5mg b.d. every other day. Median maintenance dose is 1.0mg/24h. Uncommon to need >3.0mg/24h. |
| Quetiapine |
Start with 12.5mg b.d.
If necessary, increase in 12.5-25mg increments. Mean effective dose is 40-100mg/24h. |
| Olanzapine |
Start with 2.5mg at bedtime and p.r.n.
If necessary, increase to 5-10mg at bedtime. |
| Lorazepam |
0.5mg at bedtime and p.r.n.
Should not be used as single agent first-line as may cause paradoxical worsened delirium. |
Management of the confused and agitated patient
- Subcutaneous Haloperidol 1.0-2.5mg stat and q2h p.r.n. (not more than 5mg per day). As IV Haloperidol can cause prolongation of QTc, baseline ECG is required before administration for doses >2mg/day, unless patient is near end of life and risk of prolonged QTc is irrelevant. There is no evidence presently for risk of prolonged QTc for subcutaneous route.
- Subcutaneous Haloperidol infusion may be started if more than 3 doses of p.r.n. doses are needed/24h. Doses range from 3-10mg/24h.
- Look out for extrapyramidal side effects, especially stiffness in the elderly.
- May need subcutaneous Midazolam 1.0-2.5mg p.r.n., if patient is very restless and uncooperative.
If symptoms are not controlled with measures outlined here, please consult your local palliative care service.