Lecture 14: Acute Psychosis and Delirium Flashcards
What is acute psychosis?
Psychosis is where a person loses some contact with reality.
Has three stages; prodromal, acute, recovery
Main symptoms are hallucinations delusions and cognitive impairment
Acute psychosis is deemed to be a psychiatric emergency in which prompt treatment is necessary
What are the potential causes of acute psychosis?
- Part of a neurological condition such as dementia, Alzheimers or Parkinsons
- Triggered by a brain injury
- A side effect of medication
- An effect of illegal drugs such as cxannabis
- An effect of illegal drugs or alcohol withdrawal
- Triggered by childbirth or menopause
- Triggered during times of severe stress or anxiety
What is the treatment for acute psychosis?
Rule out the physical cause
Antipsychotic medication; choice will be based on patient taking these factors into consideration;
- Metabolic (including weight gain and diabetes)
- Extrapyramidal ( including akathisia, dyskinesia and dystonia)
- Cardiovascular (including prolonging the QT interval)
- Hormonal (including increasing plasma prolactin
- Other (including unpleasant subjective experiences)
Antipsychotics can reduce some symptoms relatively quickly like anxiety but can take longer (several weeks) to reduce psychotic symptoms.
- Psychological interventions such as CBT
- In instances of drug induced psychosis – cessation or controlled withdrawal of the drug is necessary.
Describe emergency sedation
In medical and pychiatric emergencies for any non detained patient, common law allows treatment to protect patients lifes and well being or well being of others. No certification is needed beyond description of the avction in the case notes. However, any patient who has capacity to make or withhold concent cannot be given medical treatment without that consent.
The Mental Health (Care and Treatment) (Scotland) Act 2003 allows for the administration of medication to treat mental disorder (includes acutely disturbed behaviour secondary to delirium and dementia) without and/or against consent of patient. It does not allow administration of non-psychiatric treatments without consent
What is delirium?
It is inattention, disorganized thinking, memory impairment, disorientation, altered level of consciousness, acute onset, perceptual disturbance, psychomotor agitation or retardation, inattention
Causes you to not notice what is going on around you, unsure about where you are or what you are doing there, unable to follow a conversation or to speak clearly, be very agitated or restless, unable to sit still and wander around, be very slow or sleepy, sleep during the day, but wake up at nigth, have moods that change very quickly - can feel frightened, anxious, depressed or irratable, have vivid dreams - these can be frightening and may carry on when you wake up. Worry that other people are trying to harm you. Hear noises or voices when there is nothing or no one to cause them. See people or things that arent there
1-2 in 10 hospital inpatients will experience delirium during a hospital stay.
In people who experience delirium during a hospital stay – this is associated with an increased risk of mortality than those who do not experience delirium.
Delirium can come on suddenly and often has a physical cause.
Delirium can cause distress to the person experiencing it and their friends/family.
Delirium can occur in any setting but is commonly seen in the following:
Critical care (up to 75%)
Post surgical wards (10-50%)
Care of the elderly wards (10-20%)
Community?
What is the pathophysiology of delirium?
Pathophysiology remains unclear. In general, imaging reveals disruptions in higher cortical functioning in multiple unrelated areas of the brain.
Electroencephalographic (EEG) studies show diffuse slowing of cortical activity
Theories point to the role of neurotransmitters, inflammation and chronic stress on the brain.
Dopaminergic excess also contributes
Chronic hypercortisolism, as induced by chronic stress secondary to illness or trauma, may also contribute to onset of delirium.
What is the diagnosis of delirium?
The pateint must show all 4:
A disturbance in attention (i.e., reduced clarity of awareness of the environment) is evident, with reduced ability to focus, sustain, or shift attention. This disturbance in consciousness might be subtle, initially presenting solely as lethargy or distractibility, and might be frequently dismissed by clinicians and/or family members as being related to the primary illness.
A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance not better accounted for by a pre-existing or evolving dementia.
The disturbance develops over a short period of time (usually hours to days), represents an acute change from baseline, and tends to fluctuate during the course of the day.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition, substance intoxication, or substance withdrawal. The changes in attention and cognition must not occur in the context of a severely reduced level of arousal, such as coma.
What is 4AT?
Used to diagnose delirium
- Alertness - normal 0 (fully alert, but not agitated, throughout assessment)
Mild sleepiness for <10 seconds after waking, then normal - 0
Clearly abnormal - 4 - AMT4 (Age, date of birth, place - name of the hospital or building, current year
No mistakes - 0
One mistake - 1
Two or more mistakes or untestable - 2 - Attention (months of the year backwards from December)
7 or more correct - 0
Starts but scores less than 7/ refuses to start - 1
Untestable - 2 - Acute change or fluctuating course
No - 0
Yes - 4
How do you prevent delirium?
Prevention measures include:
- 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.
What medications cause delirium?
Medicines with anticholinergic properties e.g. hyoscine and tricyclic antidepressants
Anti-epileptics (including when used for neuropathic pain)
Opioids (particularly tramadol)
Benzodiazepines
Steroids
Antihistamines (sedating and non-sedating)
What is the TIMEapproach to medication review
Triggers:
* Taking medication known to predispose to delirium?
* Recent dose changes, new medicines or new interactions?
* Change in clinical status e.g. impaired renal or liver function leading to drug accumulation?
* Non-compliance e.g. overuse of a medicine known to precipitate delirium/underuse of a beneficial medicine?
* Polypharmacy?
Investigate:
- Undertake Medicines Reconciliation andinvestigaterecent changes to medicines (in particular analgesics changed from regular to PRN.
Manage
1) Develop and document amanagementplan
Consider stopping (or reducing the dose of) medicines which confer a risk of delirium. Remember: i) abrupt withdrawal of some medicines, e.g. benzodiazepines, can precipitate a withdrawal syndrome and ii) to confirm the indication for the medicine prior to altering the prescription e.g. before making changes to gabapentin, establish if it is indicated for pain or seizures.
Reduce polypharmacy and stop unnecessary medications
Consider temporarily withholding medicines not essential in the short term e.g. statins, antihypertensives (especially if unwell or BP low) and supplements such as calcium, iron and folate.
Remember:some medicines may be required for risk reduction and should not be stopped e.g. analgesia for a hip fracture or laxatives for opioid-induced constipation; particularly important as both pain and constipation are known contributory factors for delirium.
2) Analgesics and delirium
Analgesics are a risk factor for delirium but so is pain; therefore uncontrolled pain must be managed.
Patients with delirium may struggle to express their pain and behavioural changes may be key. In such circumstances consider using theAbbey Pain Tooland prescribe analgesics regularly as well as PRN.
Although opioids are considered potential triggers for delirium, small doses (with careful dose titration) of oral morphine or oxycodone can be very useful if paracetamol ineffective and other analgesics poorly tolerated.
3) If delirium is present,managesymptoms
Agitation may be due to a physical cause (pain, urinary retention) – manage this first. Medicines to treat psychotic symptoms of delirium are a last resort. Use only if:* non pharmacological methods fail AND* there is significant distress to the patient, danger to themselves or others, or refusal to accept necessary treatment
Engage
Engage with patient/carer to determine the indication for specific medicines and discuss the rationale for any medication changes.
Communicate and document all medication changes to the patient’s clinical team in both Acute and Primary Care.
Treatment:
Treat underlying cause if obvious – might not always be obvious or could be multifactorial.
Treatment usually supportive until period of delirium has resolved.
Talk calmly to the patient and try to find out what is making them agitated.
Ensure the patient is wearing their glasses or hearing aid if applicable.
Avoid crowding the patient and allow them to mobilise if safe to do so.
Investigate and treat all identified causes of delirium using the TIME checklist as a guide.
If patient is agitated / distressed, consider asking for additional help to assist.
Considerasking a family member to help reassure and support care.
If the patient is considered a danger to themselves or others then consider pharmaceutical management.
Think about patient characteristics before deciding on pharmaceutical management. High risk of falls, aspiration, patients with dementia and Parkinson’s disease all need special consideration.
What is the pharmacological treatment for delirium?
- Antipsychotics:
Avoid in PD and lewy body dementia due to risk of Extrapyrimidal side effects. Can prolong QT interval
- 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 medication: oral risperidone 250 to 500mcg (up to a maximum of 2mg in 24 hours) Use lower dose range in frail or elderly patients - Benzodiazapines
If antipsychotics are contraindicated then cosider
- Lorazepam 0.5-1mg orally (max 2 mg/24 hours)
- If oral not possible, then midazolam 2mg IM (max 6 mg/24 hours)
Describe alcohol withdrawal, the symptoms, treatment.
Alcohol withdrawal delirium can start 2-3 days after cessation of alcohol in someone who is dependant on alcohol.
Symptoms can last up to a week but most likely 2-3 days. Include tremor, confusion, sweating, drowsiness, fever, mood swings, high blood pressure, tachycardia, altered respiratpy rate, hallucinations, seizures. If left untreated can lead to patient hard and death
Symptom triggered: Glasgow Modified Alcohol Withdrawal Scale (GMAWS) or Clinical Institute Withdrawal Assessment for Alcohol (CIWA).
Treatment: 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
