Ruling out delirium: Therapeutic principles of withdrawing and changing medications

In general, there are no firm rules for how to taper and discontinue potentially deliriogenic medications, as both the need to taper and the best strategy for doing so depends on a number of factors and requires clinical judgement. When determining how quickly to withdraw a potentially offending medication in a patient with suspected delirium, clinicians should consider:

Dosage and duration of treatment. Consider tapering and discontinuing benzodiazepines in a patient who is taking more than the minimal scheduled dosages for ≥2 weeks, especially after 8 weeks of scheduled treatment. Consider tapering opioids in a patient taking more than the minimal scheduled dosage for more than a few days. When attempting to rule out delirium, taper opioids as quickly and as safely possible, with a recommended reduction of ≤20% per day to prevent withdrawal symptoms. In general, potentially deliriogenic medications can be discontinued without tapering if they are taken on a non-daily, as-needed basis.

The half-life of a medication determines both the onset and duration of withdrawal symptoms. Withdrawal occurs earlier when discontinuing medications with short

elimination half-lives (usually within 1 to 2 days) and might not emerge until 3 to 8 days after discontinuation for medications with a half-life >24 hours. Many resources suggest switching to an agent with a longer half-life when tapering and discontinuing benzodiazepines or opioids to provide a smoother withdrawal (Table 2). When ruling out delirium in patients with mild dementia, particularly in a geriatric patient with reduced medication clearance, avoid switching to a longer-acting benzodiazepine or opioid because this could prolong delirium symptoms.

Nature of withdrawal symptoms. In patients with suspected delirium, tapering over weeks or

months—often recommended for sedative-hypnotics and opioids—is not a realistic option; however, stopping the medication abruptly can lead to intolerable withdrawal symptoms (Table 3). Avoiding withdrawal from benzodiazepines is particularly important because of the potential for severe complications, including seizures and delirium, and possibly death. Withdrawal seizures are especially common with alprazolam because of its short half-life, so additional caution is warranted when tapering and discontinuing this medication. Withdrawal from opioids or anticholinergics generally is not life-threatening, but a brief taper of these medications can be considered, particularly when high dosages have been prescribed, to minimize patient discomfort.

Care setting. When tapering and discontinuing a medication, regularly monitor patients for withdrawal symptoms; slow or temporarily stop the taper if withdrawal symptoms occur. Because close monitoring is easier in an inpatient vs an outpatient care setting, more aggressive tapering over 2 to 3 days generally can be considered, although more gradual tapering might be prudent to ensure safety of outpatients.