Management of Refractory Agitation in Patients with Infectious Hydrocephalus

Initial Assessment and Intervention

The American Geriatrics Society recommends investigating reversible causes of agitation/delirium, including neurological, metabolic, infectious, and substance withdrawal causes, before intensifying pharmacotherapy 2, 3
The National Comprehensive Cancer Network suggests evaluating for signs of increased intracranial pressure, progression of hydrocephalus, or new neurological events, and considering neuroimaging if there is deterioration 2, 3
Metabolic causes, such as hyperglycemia, electrolyte imbalances, and renal or hepatic dysfunction, should be assessed and addressed 2, 3
Infectious causes, including active infection or progression of central nervous system infection, should be evaluated and treated 2, 3
Urinary retention or constipation should be examined and managed 2, 3
Substance withdrawal, including alcohol or benzodiazepine withdrawal, should be assessed and treated with benzodiazepines as first-line therapy 7, 8

The Journal of the National Comprehensive Cancer Network recommends adding lorazepam 0.5-2 mg every 4-6 hours as needed to the current therapy for refractory agitation 1, 2, 3
If agitation persists, haloperidol can be titrated upward in increments of 0.5-1 mg until adequate control is achieved, with a maximum dose of 10 mg/day 1, 2, 3
The combination of benzodiazepines and haloperidol may produce faster sedation than monotherapy 4, 5, 6
If agitation is severe and unresponsive, haloperidol 0.5-2 mg IM/IV every 1 hour as needed can be considered 1, 2, 3

The American Geriatrics Society suggests evaluating response to interventions every 1-2 hours and reevaluating the need for medications daily with a physical examination 7
Doses should be reduced depending on renal or hepatic function 1, 2, 3
Consultation with psychiatry or palliative care should be considered if agitation remains inadequately controlled 1, 2, 3