ACUTE PSYCHOSIS AND DELIRIUM Flashcards
acute psychosis
psychosis is where a person loses some contact with reality
main symptoms are hallucinations, delusions and cognitive impairment
3 stages of acute psychosis
prodromal
acute
recovery
potential causes of psychosis
- 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
treatment for psychosis
antipsychotic medication + psychological intervention (CBT)
patient factors to consider when choosing an antipsychotic for psychosis
- metabolic (inc. weight gain and diabetes)
- extrapyramidal (inc. akathisia, dyskinesia and dystonia)
- cardiovascular (prolonged QT interval)
- hormonal (inc. increased plasma prolactin)
- other
drug induced psychosis
cessation or controlled withdrawal of the drug is necessary
how long do antipsychotics take to reduce symptoms
can reduce symptoms relatively quickly like anxiety but can take longer (several weeks) to reduce psychotic symptoms
delirium symptoms
- 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
pathophysiology of epilepsy
- EEG studies show diffuse slowing of cortical activity
- pathogenesis of delirium points to the role of neurotransmitters, inflammation and chronic stress on the brain
4 main categories to be diagnosed with delirium
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
what does ‘a disturbance in attention’ mean in delirium
- 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
what does ‘a change in cognition’ mean in delirium
such as:
memory deficit
disorientation
language disturbance
prevention measures against delirium
- 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
medicines to review with delirium
- medicines with anticholinergic properties (e.g. hyoscine and TCAs)
- AEDs (inc. for neuropathic pain)
- opioids (esp. tramadol)
- benzodiazepines
- steroids
- antihistamines
TIME for medication review
Triggers
Investigate
manage
engage
antipsychotic medication for delirium/psychosis
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
benzodiazepines for delirium/psychosis
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)
timeline for alcohol withdrawal
‘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
symptoms of alcohol withdrawal
tremor
confusion
sweating
drowsiness
fever
mood swings
high BP/tachycardia
altered RR
hallucinations
seizures
treatment for alcohol withdrawal
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
