delirium and emergency psych Flashcards
DELIRIUM: A ROSE BY ANY OTHER NAME…
Encephalopathy ICU psychosis Cerebral insufficiency Change in mental status Acute brain failure
=Is a medical emergency
DELIRIUM: What is it?
Reversible neuropsychiatric syndrome with a specific cause (medical condition, substance intoxication/withdrawal)
Fluctuating mental status (waxing/waning)
Acute onset (hours to days)
Hypoactive, hyperactive, or mixed
Withdrawal and non-withdrawal types
Signs must not be accounted for by NCD (dementia)
DELIRIUM VS. DEMENTIA
DELIRIUM:
Acute onset
Acute chg in cognition
Disrupted attention
Waxing/waning
Disorganized, confused speech
MAJOR/MILD NCD: Progressive decline Progressive cognitive changes Attention intact No waxing/waning (except DLB)
Poverty of speech
DELIRIUM: What does it look like?
Picking at the air?
Disturbances in some/all/many of the following areas: Consciousness Attention (serial 7s) & awareness Psychomotor Emotional Cognitive (memory, orientation, language, perception or visuospatial ability) Sleep-wake cycle * Vital signs (usually)
DELIRIUM: So what?
Complicates hospitalizations, esp for elderly
Delirium cost Medicare $7 billion in 2006
Can increase hospital costs up to 40%
Most cases are undiagnosed or misdiagnosed (missed dx –> increased hospital mortality)
Likely causes long-term cognitive decline, is a significant risk factor for NCD (dementia), & may hasten mental decline in pts already w/dementia
Poor prognostic indicator: approx 20-40% mortality rate in 12 months
DELIRIUM: What causes it?
A lot! Likely not the direct result of the cause but rather a series of events Role of neurotransmitters: ↓ acetylcholine ↑ dopamine Others
delirium-causing meds
Antihypertensives Antipsychotics Anticholinergics (“mad as a hatter…”) Antibiotics Antidepressants Disulfiram, Lithium Opioids Anticonvulsants Cytotoxic agents
delirium- metabolic causes
Post-surgery derangements Fever Anemia Dehydration Hepatic failure Hyper/hypoglycemia Hyper/hypothyroidism Hypoxia/Hypercapnia
delirium - infectious causes
UTI (esp in elderly) URI Pneumonia Cellulitis Sepsis
other causes of delirium
Intoxication/Withdrawal Cerebrovascular dz Pulmonary dz (PE, COPD) Cardiovascular dz (CHF, MI, Dysrhythmia, etc) Head trauma Burns
DELIRIUM: How is it treated?
- Address and treat the underlying cause
- Order all necessary/appropriate lab tests (NH3, CBC, UA, Basic met, liver function, EKG, CXR, TSH, Blood gases, LP, CT/MRI, etc)
Orientation: clocks, calendars, familiar pictures/music, proper sleep structuring
Discontinue anticholinergic meds
Discontinue all unnecessary meds
- Low-dose* antipsychotics as appropriate
- Haloperidol 1-2mg q2-4 hrs prn has proven efficacy (Black Box…)
- Avoid anticholinergic antipsychotics (eg, Olanzapine, Clozapine, Chlorpromazine, etc)
- CNS will be highly sensitive to meds so watch side efx
- Can ↑ QT interval and ↓ seizure threshold
No benzodiazepines except in alcohol/benzo withdrawal delirium
DELIRIUM: A word about prevention…
Identify pts at high-risk for delirium, if possible (Major/Mild NCD, prev hx of delirium, ≥65yo, multiple meds/comorbidities, substance use, sensory impairment, etc)
Ensure pt has adequate sensory orientation equipment (glasses, hearing aids, etc) and that clocks and calendars are accurate
Encouragement of proper sleep-wake cycle to highest degree possible
Trend in treatment is toward prevention. Could significantly affect pt outcome & costs. Prophylactic tx being used/considered: haloperidol, 2nd generation antipsychotic, melatonin, gabapentin, lower propofol levels, etc.
EMERGENCY PSYCHIATRY: Risk factors for violence
The single best predictor of violence is a previous, personal history of violence Command hallucinations Stated intent/desire to harm self/others Antisocial or borderline personality disorder Substance use Delirium Major/Mild NCD (Dementia) Head trauma
EMERGENCY PSYCHIATRY: Management
Empathetic, calm approach to the patient
Speak softly, be careful with eye contact
Acknowledge and validate the patient’s feelings
Enforce boundaries in a friendly but firm manner
Watch the body language
Offer food and/or medication
Listening > talking
If necessary, safely escort pt to seclusion area and administer meds if necessary
Physical restraints should be removed as soon as is safely possible
Restraints can never be used as punishment
Restraints can lead to death (suffocation, rhabdomyolysis, etc)
EMERGENCY PSYCHIATRY:Suicide
Always ask about suicide (you will not put thoughts of suicide into someone’s mind by asking them about it)
Hospitalize against person’s will if necessary for safety
Pts may try to self-harm in hospital
May require higher level of observation (1:1)
Assess for suicide risk factors
