what is delirium?
acute organic mental syndrome with potentially reversible impairment of consciousness and cognitive function that fluctuates in severity
delirium has what types?
- mixed (hyperactive and hypoactive type in same patient) is most common
- hypoactive; second most common
- hyperactive; least common
can a patient with dementia develop delirium in the hospital?
yes, it is superimposed on dementia
what are some risks for delirium?
- preexisting dementia
- history of HTN
- history of EtOH (>2-3 drinks/day)
- high severity of illness on admission
- coma - primary neurological, sedative induced, multifactorial
- benzos
how to assess delirium?
- must have acute onset, fluctuating course; is pt different than baseline mental status?
- must exhibit inattention; give letters attention test; positive if >2 errors
needs to exhibit 3 or 4:
- altered LOC
- disorganized thinking
how to treat delirium?
- strategies to promote patient orientation
- assess/manage environment
- control clinical parameters
- prevent/treat delirium secondary to substance abuse
how to prevent delirium?
Awakening - d/c sedation ASAP Breathing trials - wean from vent ASAP Communication/collaboration amongst staff Delirium monitoring/management Early progressive mobility and exercise
how to manage delirium pharmacologically?
generally used for hyperactive delirium not responsive to non-pharmacological measures
- treat pain with analgesics if pain is thought to be the cause
- use precedex for vented patients
- use benzos for EtOH/benzo withdrawal patients
- use precedex instead of benzos if unrelated to EtOH/benzo withdrawal
- avoid antipsychotics if risk for torsades
which antipsychotic can be used for patients with delirium who might not tolerate benzos (respiratory depression or increased agitation)? what may be an adverse effect?
haloperidol; prolongs QT interval, may cause torsades
what is dementia?
neurocognitive disorder that affects brains ability to think, reason, and remember correctly; slow, progressive and permanent (most common is Alzheimer’s)
how is depression diagnosed?
- depressed mood OR
- loss of interest or pleasure in nearly all activities
plus 4 additional S/S from the following:
- loss of appetite or weight +/-
- insomnia/hypersomnia
- psychomotor agitation or retardation
- fatigue or loss of energy
- feelings of worthlessness or guilt
- impaired thinking or concentration; indecisiveness
- suicidal thoughts/thoughts of death
how would you pharmacologically manage depression?
- tricyclics (-triptyline or -pramine); lethal in overdose (tachycardia, hypotension, fatal arrhythmias), vertigo, dry mouth, dental caries, urinary retention, constipation, orthostatic hypotension, prolonged QT
- SSRIs (-xetine, -lopram, -faxine) first line; adverse effects dose dependent, most subside after 1-2 weeks or after dose reduction; headache, ab pain, nausea, diarrhea, sleep changes, jitteriness or agitation; can induce manic/hypomanic episode; inhibit metabolism of antiarrhymics, benzos, warfarin, tricyclics, neuroleptics
what are some signs of EtOH withdrawal?
- minor, initial changes (first 6-36 hours) tremors, mild anxiety, HA, diaphoresis, palpitations, anorexia, GI upset
- sz may occur during first 48 hours
- hallucinations after 12-48hrs
- DTs may occur 48-96hrs with delirium, agitation, tachycardia, hypertension, fever, diaphoresis
how is EtOH withdrawal treated?
- preventative therapy with benzos
- CIWA/RASS
- phenobarbital for refractory DTs
- fluids to replace deficits
- *glucose and thiamine to prevent Wenicke’s encephalopathy (gait disturbances, nystagmus, eye muscle paralysis) and Korsakoff syndrome (decreased spontaneity, amnesia, denial of memory loss by making up facts)
- multivitamins with folate
- correct electrolytes
- quiet environment
- restraints prn
what are some S/S of Benzo withdrawal? and when can it happen?
- tremors, anxiety, perceptual disturbances, psychosis, sz
- 2-21 days after last dose
how is Benzo withdrawal managed?
- benzo (same agent as patient was taking chronically) or long-acting Librium as patient warrants
what are signs of opiate withdrawal? and when can it happen?
- insomnia, restlessness, yawning, lacrimation, rhinorrhea, diaphoresis; vomiting, diarrhea, fever, chills, muscle spasm, tremor, tachycardia, hypertension
- first 24hrs
how is opiate withdrawal prevented/managed?
- give opiates, preferably long-acting (methadone) in doses to control patient symptoms, gradually taper
