| Medication | Dose range | Routes of administration | Side effects | Comments |
|---|---|---|---|---|
Typical antipsychotics | ||||
Haloperidola | 0.5-2 mg every 2–12 hours | PO, IV, IM, SC | Extrapyramidal adverse effects can occur at higher doses. Monitor QT interval on electrocardiogram | Remains the gold-standard therapy for delirium. May add lorazepam (0.5–1 mg every 2–4 hours) for agitated patients. Double-blind controlled trials support efficacy in treatment of delirium. A pilot placebo-controlled trial suggests lack of efficacy when compared to placebo |
Chlorpromazinea | 12.5–50 mg every 4–6 hours | PO, IV, IM, SC, PR | More sedating and anticholinergic compared with haloperidol. Monitor blood pressure for hypotension. More suitable for use in intensive care unit settings for closer blood pressure monitoring | May be preferred in agitated patients due to its sedative effect. Double-blind controlled trials support efficacy in treatment of delirium. No placebo-controlled trials |
Atypical antipsychotics | ||||
Olanzapinea | 2.5–5 mg every 12–24 hours | POb, IM | Sedation is the main dose-limiting adverse effect in short-term use | Older age, pre-existing dementia, and hypoactive subtype of delirium have been associated with poor response. Double-blind comparison trials with haloperidol and risperidone support efficacy in the treatment of delirium. A pilot placebo-controlled prevention trial suggested worsening in delirium severity. A placebo-controlled study is supportive of efficacy in reducing delirium severity and duration |
Risperidonea | 0.25–1 mg every 12–24 hours | POb | Extrapyramidal adverse effects can occur with doses > 6 mg/day. Orthostatic hypotension | Double-blind comparison trials support efficacy in the treatment of delirium. No placebo control trials |
Quetiapinea | 12.5–100 mg every 12–24 hours | PO | Sedation, orthostatic hypotension | Sedating effects may be helpful in patients with sleep–wake cycle disturbance. Pilot placebo-controlled trials suggest efficacy in treatment of delirium. However, studies allowed for concomitant use of haloperidol which makes the results difficult to interpret |
Ziprasidone | 10–40 mg every 12–24 hours | PO, IM | Monitor QT interval on electrocardiogram | Placebo-controlled, double blind trial suggests lack of efficacy in the treatment of delirium |
Aripiprazolec | 5–30 mg every 24 hours | POb, IM | Monitor for akathisia | Evidence is limited. A prospective open label trial suggests comparable efficacy to haloperidol. No placebo-controlled trials |
| Medication | Dose range | Routes of administration | Side effects | Comments |
|---|---|---|---|---|
Typical antipsychotics | ||||
Haloperidola | 0.5-2 mg every 2–12 hours | PO, IV, IM, SC | Extrapyramidal adverse effects can occur at higher doses. Monitor QT interval on electrocardiogram | Remains the gold-standard therapy for delirium. May add lorazepam (0.5–1 mg every 2–4 hours) for agitated patients. Double-blind controlled trials support efficacy in treatment of delirium. A pilot placebo-controlled trial suggests lack of efficacy when compared to placebo |
Chlorpromazinea | 12.5–50 mg every 4–6 hours | PO, IV, IM, SC, PR | More sedating and anticholinergic compared with haloperidol. Monitor blood pressure for hypotension. More suitable for use in intensive care unit settings for closer blood pressure monitoring | May be preferred in agitated patients due to its sedative effect. Double-blind controlled trials support efficacy in treatment of delirium. No placebo-controlled trials |
Atypical antipsychotics | ||||
Olanzapinea | 2.5–5 mg every 12–24 hours | POb, IM | Sedation is the main dose-limiting adverse effect in short-term use | Older age, pre-existing dementia, and hypoactive subtype of delirium have been associated with poor response. Double-blind comparison trials with haloperidol and risperidone support efficacy in the treatment of delirium. A pilot placebo-controlled prevention trial suggested worsening in delirium severity. A placebo-controlled study is supportive of efficacy in reducing delirium severity and duration |
Risperidonea | 0.25–1 mg every 12–24 hours | POb | Extrapyramidal adverse effects can occur with doses > 6 mg/day. Orthostatic hypotension | Double-blind comparison trials support efficacy in the treatment of delirium. No placebo control trials |
Quetiapinea | 12.5–100 mg every 12–24 hours | PO | Sedation, orthostatic hypotension | Sedating effects may be helpful in patients with sleep–wake cycle disturbance. Pilot placebo-controlled trials suggest efficacy in treatment of delirium. However, studies allowed for concomitant use of haloperidol which makes the results difficult to interpret |
Ziprasidone | 10–40 mg every 12–24 hours | PO, IM | Monitor QT interval on electrocardiogram | Placebo-controlled, double blind trial suggests lack of efficacy in the treatment of delirium |
Aripiprazolec | 5–30 mg every 24 hours | POb, IM | Monitor for akathisia | Evidence is limited. A prospective open label trial suggests comparable efficacy to haloperidol. No placebo-controlled trials |
Despite shortcomings of the studies described in the text there is US Preventive Services Task Force (USPSTF) level I evidence for the use of haloperidol, risperidone, olanzapine, and quetiapine in the treatment of delirium.
Risperidone, olanzapine, and aripiprazole are available in orally disintegrating tablets. There have been no intervention or prevention trials with the use of recently released antipsychotics including paliperidone, iloperidone, asenapine, or lurasidone in the treatment or prevention of delirium.
There is USPSTF level II-2 evidence for the use of aripiprazole in the treatment of delirium.
