Sound the Alarm
This scale grades sedation and agitation severity in hospitalized patients but does NOT diagnose delirium.
Richmond Agitation-Sedation Scale (RASS)
A patient presents to the ED acutely agitated with an unclear cause. Per Project BETA, what's the recommended first step before any medication is chosen?
Verbal de-escalation, followed by selecting pharmacotherapy based on the most likely etiology, not a standard regimen
A hemodynamically stable patient in alcohol withdrawal is acutely agitated. Which drug class is preferred?
Benzodiazepines
A mechanically ventilated ICU patient with hemodynamic stability develops hyperactive delirium. What advantage does dexmedetomidine offer over GABAergic sedatives like benzodiazepines or propofol?
Lower delirium incidence/duration compared to GABAergic agents
This is the only second-generation antipsychotic FDA-approved specifically for agitation in Alzheimer's dementia.
Brexpiprazole
A patient has an acute, fluctuating change in mental status and difficulty focusing attention, but thinking is organized and she is alert. Is her CAM positive for delirium?
Bonus (100pts): What criteria led you to your answer?
No.
Bonus (100pts): CAM requires Features 1 AND 2, plus either 3 OR 4. She has 1 and 2 but neither 3 nor 4, so CAM is negative.
Per the 2018 PADIS guidelines, is pharmacologic or nonpharmacologic therapy first-line for delirium prevention, and where does medication fit in?
Nonpharmacologic, multicomponent interventions (sleep, mobility, hearing/vision, cognition) are first-line; pharmacologic therapy is adjunctive only
You're asked to redose IM midazolam in an agitated patient who received 5 mg IM four minutes ago and remains agitated. What's wrong with this plan?
IM midazolam's max single dose is 10 mg with a redosing interval of every 15 minutes. A 5-minute redosing interval applies to the IV formulation (0.05 mg/kg, max 5 mg, may repeat q5min), not IM
You're transitioning a patient off IV dexmedetomidine to an oral agent for ongoing delirium. Which drug could fill this role, and what pharmacodynamic difference makes it more likely to cause cardiovascular effects than dexmedetomidine?
Clonidine
Lower alpha2:alpha1 selectivity, causing greater alpha1-mediated cardiovascular effects -> more hypotension/bradycardia risk
A 9-year-old is admitted with acute agitation. He is intermittently cooperative but gags on and spits out tablets, and the team wants to avoid an injection if possible. Which olanzapine formulation and administration approach is most appropriate?
Orally disintegrating tablet (Zydis) placed on the tongue to dissolve in saliva and swallowed
This feature distinguishes delirium from dementia: in delirium, symptoms follow this course, while dementia has relatively preserved attention/awareness early on.
An acute onset with a fluctuating course
The 2016 Neufeld et al. meta-analysis of 19 studies looked at antipsychotics for delirium prevention and treatment. What was the key takeaway for how you'd counsel a team wanting to start prophylactic haloperidol?
Antipsychotics showed no significant benefit for preventing or treating delirium (no reduction in incidence, duration, severity, or LOS)
Evidence doesn't support routine use for either purpose
A patient with a documented history of schizophrenia becomes severely agitated and requires rapid parenteral sedation. The team proposes IM ketamine. What do you say as the clinical pharmacist?
Recommend against ketamine as it may worsen psychosis in patients with known psychiatric disorders. Per the Project BETA algorithm, psychosis-driven agitation should instead be treated with a low-dose antipsychotic (an SGA is preferred for lower EPS risk), with benzodiazepines added if needed
A patient with delirium and a history of Parkinson disease needs an antipsychotic for severe agitation. Which agent is preferred?
Quetiapine
These medications, flagged by the AGS Beers Criteria as potentially inappropriate in adults ≥65, are commonly avoided because they raise the risk of falls, confusion, and delirium.
Benzodiazepines (and Z-drugs), first-generation antihistamines, tricyclic antidepressants, and other strongly anticholinergic drugs
This ICU delirium screening tool becomes invalid when a patient's RASS score is below -3.
CAM-ICU
An elderly patient with dementia-related agitation is being considered for an antipsychotic. Per the Beers Criteria, what must you tell the team about the risk?
All antipsychotics carry a boxed warning for increased mortality in older adults with dementia-related psychosis
A 70 kg patient requires IM ketamine for severe agitation. You choose the reduced dose protocol. What dose range would you give?
2–3 mg/kg IM = 140–210 mg, versus the traditional 4–6 mg/kg protocol, which is linked to higher intubation rates
Explain what the PADIS guideline update states about the use of melatonin/ramelteon in delirium and the reasoning behind this recommendation.
The PADIS focused update now issues a conditional recommendation SUGGESTING melatonin (not ramelteon) for adult ICU patients, reversing the 2018 guideline's "no recommendation" stance.
Low-certainty RCT data suggest melatonin modestly lowers delirium incidence with a favorable safety profile, low cost, and biologic plausibility, though the "conditional" strength reflects heterogeneous, low-quality evidence and no proven benefit on delirium duration, ICU stay, or mortality
On a general medicine floor, the team is managing an agitated patient with dementia and requests divalproex for behavioral control, since "it's worked before" for other agitated patients. What should you tell the team about the evidence for this practice?
VPA has no established effective dose and shows no benefit over placebo for agitation, with more ADEs
Reserve it for patients with a comorbid seizure disorder or mood disorder, where it has an actual indication. Redirect the team toward evidence-based options for the specific dementia subtype instead
This pediatric delirium screening tool covers ages 3 months to 18 years, takes about 2 minutes, and uniquely differentiates withdrawal from delirium.
SOS-PD (Sophia Observation withdrawal Symptoms-Pediatric Delirium)
NYP's hyperactive delirium ED guideline and Project BETA both emphasize matching drug choice to a specific clinical scenario rather than using a one-size-fits-all "chemical restraint." Give an example of how drug choice changes based on suspected etiology.
ETOH/benzo withdrawal → benzodiazepines; psychosis → antipsychotic ± benzodiazepine; delirium → correct the underlying cause and avoid benzodiazepines (unless etiology is withdrawal); undifferentiated → benzodiazepines empirically
An agitated patient with known QTc prolongation needs rapid IM sedation for psychotic agitation. Which antipsychotic agents indicated for agitation should be avoided?
Avoid chlorpromazine, droperidol, haloperidol, and ziprasidone
Haloperidol is ordered for scheduled delirium management. What does SCCM PADIS say about the strength of evidence supporting this practice?
PADIS states there is insufficient evidence to recommend routine haloperidol use for either delirium treatment or prevention
A patient with Alzheimer's disease is agitated. She has a new mild resting tremor noted on exam with a history of akathisia. Her baseline ECG shows a borderline-prolonged QTc. Which agent would you recommend for agitation maintenance therapy?
Dextromethorphan-bupropion: As the first non-antipsychotic FDA-approved for AD agitation, it avoids any dopamine-blocking or partial-agonist activity that risperidone or aripiprazole carry, which could worsen emerging EPS in this patient. Citalopram can be QT prolonging, so we would avoid as well.