Table 5.

Pharmacologic Therapy of Agitated Delirium.^*

Agent	Drug Class	Dosing†	Routes	Degree of Sedation	Risk of EPS	Adverse Effects	Comments
Haloperidol	Typical antipsychotic	Initial: 0.25–0.5 mg Maximum: 3 mg	Oral, IM, or IV	Low	High	Risk of EPS increases if daily dose exceeds 3 mg	Longest track record in delirium; several large trials are ongoing
Risperidone	Atypical antipsychotic	Initial: 0.25–0.5 mg Maximum: 3 mg	Oral or IM	Low	High	Slightly less risk of EPS than with haloperidol at low doses	Small trials; considered to be very similar to haloperidol
Olanzapine	Atypical antipsychotic	Initial: 2.5–5 mg Maximum: 20 mg	Oral, sublingual, or IM	Moderate	Moderate	More sedating than haloperidol	Small trials; oral route is less effective than other routes for management of acute symptoms
Quetiapine	Atypical antipsychotic	Initial: 12.5–25 mg Maximum: 50 mg	Oral	High	Low	Much more sedating than haloperidol; risk of hypotension	Small trials; can be used, with caution, in patients who have parkinsonism
Ziprasidone	Atypical antipsychotic	Initial: 5–10 mg Maximum: 40 mg	Oral or IM	Moderate	Moderate	More sedating than haloperidol; risk of cardiac arrhythmia, heart failure, and agranulocytosis	Owing to risks, used primarily in ICU; large trial is ongoing
Lorazepam	Benzodiazepine	Initial: 0.25–0.5 mg Maximum: 2 mg	Oral, IM, or IV	Very high	None	More paradoxical excitation and respiratory depression than with haloperidol	Second-line agent; use in sedative and alcohol withdrawal or if patient has a history of the neuroleptic malignant syndrome

^*Use of all these drugs for delirium is off-label in the United States. Atypical antipsychotic agents have been tested primarily in small noninferiority trials with haloperidol and recently in small placebo-controlled trials in the intensive care unit (ICU). The Food and Drug Administration (FDA) requires a “black box” warning for all atypical antipsychotics because of increased risks of cerebrovascular events (e.g., stroke) and death among patients with dementia. Typical antipsychotic agents have an FDA “black box” warning because of an increased risk of death among patients with dementia. EPS denotes extrapyramidal symptoms, IM intramuscular, and IV intravenous.

^†The doses recommended in this table are for older adults. “Initial” represents the initial dose for an acutely agitated older patient; the dose may need to be repeated. “Maximum” represents the maximum recommended cumulative daily dose — that is, the sum of all as-needed and scheduled doses over a period of 24 hours. Somewhat higher doses may be used in younger patients if the side-effect profile is acceptable.