Psychosomatics 46:90-91, February 2005
© 2005 The Academy of Psychosomatic Medicine
Prolonged Delirium Managed With Risperidone
James A. Bourgeois, O.D., M.D., and
Donald M. Hilty, M.D., Sacramento, Calif.
TO THE EDITOR: We present a case of prolonged delirium after multiple trauma with medical complications, including pneumonia and muscular rigidity. After replacement of haloperidol with risperidone and tapering of benzodiazepines, the patient’s cognition recovered, and his rigidity resolved. Consultation-liaison psychiatrists should consider the use of atypical antipsychotics for delirium, especially when side effects follow the use of typical antipsychotics.
Case Report
Mr. A, a 57-year-old man with a history of daily alcohol use, was struck by a car. He suffered loss of consciousness, lung contusion, and rib fractures. A computerized tomographic scan of his head was normal. He required intubation because of excess pulmonary secretions and diminished oxygen saturation. While intubated, he developed agitation, tachycardia, and fever. Pneumonia, sepsis, and sinusitis were treated with antibiotics. Over the first 21 hospital days, he received haloperidol, droperidol, opioids, beta-blockers, and benzodiazepines for agitation. Despite these medications, agitation with tremors, diaphoresis, tachycardia, and hypertension continued. Upon psychiatric consultation on day 23, his medications included 10 mg every 4 hours of intravenous haloperidol, 6 mg/hour of morphine sulfate, 6 mg/hour of midazolam, 5 mg every 4 hours of intravenous metoprolol, and 1 g b.i.d. of intravenous vancomycin.
A psychiatric examination revealed a temperature of 37.6°C, a pulse of 95 bpm, and a blood pressure of 159/94 mm Hg. Mr. A was restrained, diaphoretic, and tremulous, with a variable level of consciousness. He did not respond to verbal commands; his extremities were rigid. His psychiatric diagnoses were delirium, alcohol dependence, and rule-out dystonia. Since he was taking nothing by mouth, 2 mg of risperidone liquid was given through a nasogastric tube every 6 hours; haloperidol was tapered to 5 mg intravenously every 4 hours. Subsequent laboratory studies revealed an albumin level of 2.1 g/dl, an alkaline phosphatase level of 610 IU/liter, a total bilirubin level of 2.9 mg/dl, an aspartate transaminase level of 35 U/liter, an alanine transaminase level of 51 U/liter, a  -glutamyl transferase level of 261 U/liter, an NH4 level of 21 µg/dl, and a thyroid-stimulating hormone level of 2.99 mU/liter.
On day 24, midazolam was decreased to 4 mg/hour. Mr. A was more alert, less agitated, and able to respond to his name and to follow simple directions. Haloperidol was further tapered to 3 mg intravenously every 4 hours. On day 25, his agitation continued to improve; haloperidol was decreased to 2 mg intravenously every 4 hours, and midazolam was decreased to 2 mg/hour.
On day 26, Mr. A was alert and responded to his name and "yes/no" questions. Midazolam and haloperidol were discontinued. Risperidone was decreased to 1 mg every 6 hours. By day 27, his agitation was resolved. By day 28, he had a normal sleep-wake pattern, a brighter affect, good eye contact, an appropriate following of directions, improving orientation, and no rigidity. By day 31, his delirium was resolved; a partial administration of the Mini-Mental State Examination revealed a score of 21 of 22 tested items. On day 34, risperidone was changed to 2 mg at bedtime. Four days later, at discharge, risperidone was tapered to 1 mg at bedtime for 1 week with advice to then discontinue it.
Discussion
This case represents 3 weeks of multifactorial delirium (with an alcohol-withdrawal component) that was refractory to and complicated by a regimen that included haloperidol, midazolam, and opioids. It is likely that the patient’s rigidity represented extrapyramidal symptoms from haloperidol. In addition, akathisia from high-potency typical antipsychotics can overlap with the nonspecific symptom of "agitation" in a delirious patient.
Risperidone is an atypical antipsychotic with effects on dopamine and serotonin receptors. It is increasingly being used for both dementia and delirium.1–6 When used in delirium, recommended initial doses are as low as 0.5 mg/day, especially in elderly patients.1–6 An advantage of risperidone over haloperidol is a lower risk of extrapyramidal symptoms.1,2 Our patient was rigid at his initial examination. Once risperidone was started and haloperidol tapered, the rigidity cleared. During the first days of risperidone therapy, he was maintained on a midazolam taper. It is likely that midazolam controlled his symptoms of lingering alcohol withdrawal. In addition, antibiotics for his pneumonia were continued as he recovered from delirium.
Consultation-liaison psychiatrists confronting delirium patients who are not improving with typical antipsychotics or who experience extrapyramidal symptoms should consider an atypical antipsychotic. There are reports of risperidone-associated delirium; close clinical monitoring is necessary.7 There is no intravenous preparation of risperidone, but the liquid formulation can be administered through a nasogastric tube. Another option is long-acting intramuscular risperidone, which may be appropriate for a delirious patient who will not be taking anything orally for a substantial period. This preparation does not achieve therapeutic effect immediately, so alternative measures are needed temporarily. Other preparations of atypical antipsychotics that appear promising in patients who cannot safely take conventional oral preparations include orally disintegrating olanzapine and intramuscular olanzapine and ziprasidone.
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