ACUTE PSYCHOSIS AND DELIRIUM

Question 1

acute psychosis

Answer 1

psychosis is where a person loses some contact with reality

main symptoms are hallucinations, delusions and cognitive impairment

Question 2

3 stages of acute psychosis

Answer 2

prodromal
acute
recovery

Question 3

potential causes of psychosis

Answer 3

• neurological disorder (dementia, Alzheimer’s or Parkinson’s)
• triggered by a brain injury
• side effect of medication
• an effect of illegal drugs
• an effect of alcohol withdrawal
• triggered by childbirth/menopause
• triggered during times of severe stress or anxiety

Question 4

treatment for psychosis

Answer 4

antipsychotic medication + psychological intervention (CBT)

Question 5

patient factors to consider when choosing an antipsychotic for psychosis

Answer 5

• metabolic (inc. weight gain and diabetes)
• extrapyramidal (inc. akathisia, dyskinesia and dystonia)
• cardiovascular (prolonged QT interval)
• hormonal (inc. increased plasma prolactin)
• other

Question 6

drug induced psychosis

Answer 6

cessation or controlled withdrawal of the drug is necessary

Question 7

how long do antipsychotics take to reduce symptoms

Answer 7

can reduce symptoms relatively quickly like anxiety but can take longer (several weeks) to reduce psychotic symptoms

Question 8

delirium symptoms

Answer 8

• not notice what is going on around you
• be unsure about where/what you are doing there
• be unable to follow a conversation or speak clearly
• be very slow or sleepy
• quick mood changes
• vivid dreams
• hear noises or voices/see people or things that aren’t there

Question 9

pathophysiology of epilepsy

Answer 9

• EEG studies show diffuse slowing of cortical activity
• pathogenesis of delirium points to the role of neurotransmitters, inflammation and chronic stress on the brain

Question 10

4 main categories to be diagnosed with delirium

Answer 10

DMS-5-TR diagnostic test
- a disturbance in attention
- change in cognition
- disturbance develops over a short period of time (hours to days)
- disturbance caused by direct physiological consequences of a medical condition or withdrawal

Question 11

what does ‘a disturbance in attention’ mean in delirium

Answer 11

• reduced clarity of awareness of the environment
• reduced ability to focus, sustain or shift attention
• this disturbance in consciousness might be subtle, initially presenting solely as lethargy or distractibility

Question 12

what does ‘a change in cognition’ mean in delirium

Answer 12

such as:
memory deficit
disorientation
language disturbance

Question 13

prevention measures against delirium

Answer 13

• making sure care is given to people experiencing delirium by people/carers who are familiar to them
• avoid unnecessary ward or care setting moves
• medication reviews
• addressing modifiable factors

Question 14

medicines to review with delirium

Answer 14

• medicines with anticholinergic properties (e.g. hyoscine and TCAs)
• AEDs (inc. for neuropathic pain)
• opioids (esp. tramadol)
• benzodiazepines
• steroids
• antihistamines

Question 15

TIME for medication review

Answer 15

Triggers
Investigate
manage
engage

Question 16

antipsychotic medication for delirium/psychosis

Answer 16

avoid in Parkinson’s disease and Lewy body dementia (risk of severe EPS), they can prolong the QT interval and avoid if pt on other QT prolonging medication

• haloperidol 0.5-1mg orally (max 2mg/24 hours)
  if oral route not possible > haloperidol 0.5mg IM (max 2mg/24 hours)
  alternative if on QT-prolonging meds > oral risperidone 250 to 500mcg (max 2mg/24 hours) use lower dose range in frail or elderly patients

Question 17

benzodiazepines for delirium/psychosis

Answer 17

if antipsychotics are contraindicated then consider:
- lorazepam 0.5-1mg orally (max 2mg/24 hours)
if oral route not available
- midazolam 2mg IM (max 6mg/24 hours)

Question 18

timeline for alcohol withdrawal

Answer 18

‘delirium tremens’ or alcohol withdrawal delirium can start 2-3 days after cessation

symptoms can last up to a week but most likely 2-3 days

Question 19

symptoms of alcohol withdrawal

Answer 19

tremor
confusion
sweating
drowsiness
fever
mood swings
high BP/tachycardia
altered RR
hallucinations
seizures

Question 20

treatment for alcohol withdrawal

Answer 20

severe withdrawal fixed dose benzodiazepines such as:
diazepam oral 20mg 6 hourly then
diazepam oral 15mg 6 hourly for 24 hours then
10mg 6 hourly for 24 hours then
5mg 6 hourly for 24 hours then
5mg 12 hourly for 24 hours then stop