Delirium is considered in Ch§pteL4...1;2, and its special importantance in the elderly is described in Chapter 8.4.1. Delirium is frequently misdiagnosed as dementia or depression, with disastrous consequences for management. It is a frequent presenting feature of physical illness, such as myocardial infarction or pneumonia. It has high mortality (up to 30 per cent even with treatment, depending on cause and age) and may lead to serious complications such as self-injury and interference with medical procedures. Its aetiology is varied and strongly dependent on age. Important causes include the rapid withdrawal of sedative-hypnotic drugs or alcohol, and the absolute or relative overdosage of many drugs as a result of changes in drug metabolism and elimination. Postoperative delirious states are attributed to neurotransmitter imbalances. It is crucial to diagnose delirium early and treat it effectively.

The management of delirium is discussed in Chapter...i4:1.2 and Chapter..8.5..1. The following points are important in the present context: elimination or correction of the underlying causal factor (or factors) by appropriate medical or surgical intervention, and general symptomatic and supportive measures aimed at securing adequate rest, sleep, nutrition, and fluid and electrolyte balance, and optimal comfort and protection against self-injury. A detailed history of medical and illegal drug use and alcohol intake is most important. Any medication in delirious patients should be witheld or reduced, if possible. Proper fluid and electrolyte balance, nutrition, and vitamins should be provided by intravenous catheters. Many patients are lethargic and hypoactive, and have difficulty staying awake during the day, but agitated hyperactive patients need adequate sedation to avoid complications. Haloperidol is the drug of choice in a dose of 5 to 15 mg twice daily in adults, and 0.5 to 5 mg twice daily in elderly patients. In the treatment of alcohol withdrawal syndrome and hepatic encephalopathy, clomethiazol can be given in a dose of 5 to120 mg/day by mouth or 80 to 240 mg/day intravenously, depending on the clinical situation. In some countries benzodiazepines are used instead. The medical and nursing team must be taught how to provide adequate sensory stimulation and orientation to the patient. With close nursing supervision and timely sedation, physical restraints are usually unnecessary.

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