lecture 14 - acute psychosis and delirium Flashcards
disuss what psychosis and acute psychosis is. x4
Psychosis is where a person loses some contact with reality.(1)
Is thought to comprise of 3 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 potential causes of acute psychosis? x6
part of a neurological condition such as dementia, Alzheimer’s or Parkinson’s,
triggered by a brain injury,
a side effect of medication,
an effect of illegal drugs such as cannabis, or
an effect of illegal drugs or alcohol withdrawal,
triggered by childbirth or menopause, or,
triggered during times of severe stress or anxiety.
what is the treatment for psychosis and factor influencing the choice of drug for treatment?
Rule out physical cause.
Offer antipsychotic medication – choice will be based upon individual patient taking 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)(2)
Psychological interventions such as CBT.
Antipsychotics can reduce some symptoms relatively quickly like anxiety but can take longer (several weeks) to reduce psychotic symptoms.
what is the legislation for emergency sedation?
In medical and psychiatric emergencies for anynon detainedpatient, common law allows treatment to protect patient’s life and/or well-being and/or well-being of others. No certification is needed beyond description of the action in the case notes. However any patient who has capacity to make or withhold consent cannot be given medical treatment without that consent.(3)
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?
Greek word “Leros” which means “nonsense talking” and Latin word “delirare” or “delirare decedere” which means “stepping outside of the track.’(1
people who experience delirium during hospital stay will have increased mortality rates than those who do not have 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
what are symptoms of delirium? x9
altered sleep-wake cycle, inattention, disorganised thinking, memory impairment, disorientation, altered level of consciousness, acute onset, perceptual disturbance, psychomotor agitation or retardation
what setting in delirium most commonly seen in?
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 somewhat unclear.
In general, imaging reveal disruptions in higher cortical functioning in multiple unrelated areas of the brain.
Electroencephalographic (EEG) studies show diffuse slowing of cortical activity.
Theories on the pathogenesis of delirium point to the role of neurotransmitters, inflammation, and chronic stress on the brain.
Role of anticholinergic medicines?
Dopaminergic excess is also believed to contribute.
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 by the DSM-5-TR?
the patient must show all 4 of the following features:
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 are preventative measures for delirium?
Delirium is preventable in about 30% of cases (NICE).
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 may be reviewed for delirium prevention?
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 are the triggers in time approach to medicines 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?
what is to investigate in TIME approach to medicines review?
Investigate:
Undertake Medicines Reconciliation andinvestigaterecent changes to medicines (in particular analgesics changed from regular to PRN.
what is there to manage in the TIME APPROACH TO MEDICINES REVIEW?
Consider stopping or reducing dose of medicines that may cause delirium. But abrupt withdrawal of bzds can precipitate withdrawal symtopms. Also confirm indication for medicine before altering prescription eg if gabapentin for pain or seizures
Reduce polypharmacy and stop unnecessary medications
Consider temporarily withholding medicines that are not essential in short term use eg statins, antihypertensives and supplements
Analgesics can cause delirium. Use abbey pain tool for patient to express their pain and then decide if PRN use or regular
Medicines to treat psychotic symtopms are used as last resort only when all non pahramcological treatment fail and patient is at risk to themselves or others, refuse treatment and signisificant stress
what is there to engage in the TIME approach in review of medicines
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.
