Choosing Wisely:

Don’t administer “prn” (i.e., as needed) sedative, antipsychotic, or hypnotic medications to prevent and/or treat delirium without first assessing for, removing, and treating the underlying causes of delirium and using nonpharmacologic delirium prevention and treatment approaches.

Rationale and Comments: The most important step in treating delirium is identifying, removing, and treating the underlying cause(s) of delirium. Delirium is often a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple etiologies. Clinicians should therefore perform a detailed history and physical exam, order appropriate laboratory/diagnostic tests, conduct a thorough medication review, and discontinue any potentially deliriogenic medications. Because numerous medications or medication classes are associated with the development of delirium (e.g., benzodiazepines, anticholinergics, diphenhydramine, sedative-hypnotics), their administration on a prn basis should be avoided if possible. Moreover, due to the potential for harm and lack of sufficient evidence supporting the safety and efficacy of antipsychotics for the prevention and treatment of delirium, these medications should be administered only at the lowest effective dose, for the shortest amount of time, in patients who are severely agitated and/or at risk for harming themselves and/or others. In terms of delirium prevention, it is recommended health systems should implement multicomponent, nonpharmacologic interventions that are delivered consistently throughout hospitalization by the interdisciplinary team.
Sponsoring Organizations:
  • American Academy of Nursing
  • Sources:
  • American Geriatrics Society guidelines
  • Disciplines:
  • Psychiatric and Psychologic
  • Geriatric Medicine
  • References: • American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. J Am Geriatr Soc. 2015 Jan;63(1):142-50.
    • Diagnostic and statistical manual of mental disorders. (5th ed.). Washington (DC): American Psychiatric Association. 2013.
    • Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BR, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013 Jan;41(1):263-306.
    • Campbell N, Boustani MA, Ayub A, Fox GC, Munger SL, Ott C, Guzman O, Farber M, Ademuyiwa A, Singh R. Pharmacological management of delirium in hospitalized adults—a systematic evidence review. J Gen Intern Med. 2009 Jul;24(7):848-53.
    • By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015 Nov;63(11):2227-46.
    • Hawkins SB, Bucklin M, Muzyk AJ. Quetiapine for the treatment of delirium. J Hosp Med. 2013 Apr;8(4):215-20.
    • Inouye SK, Marcantonio ER, Metzger ED. Doing damage in delirium: the hazards of antipsychotic treatment in elderly persons. Lancet Psychiatry. 2014 Sep 1;1(4):312-5.

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