Psychiatry

76 yo woman with inpatient psych consult for depression

Carrie Tamarelli on Jan 26, 2018 - University of Michigan

Which of the following recommendations would be appropriate to share with the primary team to assist in the management of hypoactive delirium?

Select all that apply
Expand all answers
Promote sleep by keeping the patient’s room dark with minimal interruptions during the day
No! Promote a normal sleep-WAKE cycle by keeping the room bright with more interaction during the day. Then go ahead and minimize interruptions overnight.


Search for and treat any reversible medical issues, such as infection, dehydration, malnutrition, constipation, urinary retention, pain, or medications that might be contributing to her delirium.
Yes! This is a mainstay of delirium prevention and management.


Use restraints to maintain safety in case she becomes more active
No! This is less of an issue in hypoactive delirium, but can become problematic in hyperactive or mixed delirium. Minimize use of restraints, as well as any unnecessary lines or tubes. Use behavioral redirection as much as possible.


Request family to bring in hearing aids and glasses
Yes. If available, these sensory aids should be used during the day.


Assist in early mobilization with nursing and PT staff as tolerated
Yes. Keep her moving!


Querques J, et al. Postoperative delirium. J Amer Psych. 2008. 165(7)803-812.

Maldonado JR. Delirium in the acute care setting: Characteristics, diagnosis and treatment. Crit Care Clin. 2008. 24:657-722.

Which of the following medications should be avoided in our delirious, elderly patient?

Select all that apply
Expand all answers
Lorazepam
Yes, benzodiazepines are deliriogenic and should be avoided when possible. Even when treating alcohol withdrawal [1], recent data on benzodiazepine-sparing protocols support the use of gabapentin and other agents to safely manage withdrawal while minimizing the risk of delirium, which often results from the overuse of benzodiazepines in response to CIWA scores.


Prednisolone
Yes, steroids should be avoided when possible given their effects on mood as well as sleep.


Diphenhydramine
Yes, anticholinergic medications should be avoided when possible. This includes not only diphenhydramine (Benedryl) and other antihistamines, but also several other common medications with cardiovascular, central nervous system, gastrointestinal, antibiotic, immunosuppressive, and other uses that also have anticholinergic effects [2].


Quetiapine
Yes, the sedating and anti-cholinergic effects of this medication are undesirable. Other less sedating antipsychotic agents may be selected as pharmacologic therapy for hypoactive delirium, for which there is some evidence [2].


Hydromorphone
Yes, opioids should be avoided. But pain control is also important in the management of delirium, so if pain medications must be escalated to the level of opioids, hydromorphone is a reasonable choice. Hydromorphone and fentanyl have been shown to be less deliriogenic than other opioid formulations, including morphine [3].


[1] Maldonado JR. Novel algorithms for the prophylaxis and management of alcohol withdrawal syndromes—beyond benzodiazepines. Crit Care Clin. 2017. 33(3)559-599.

[2] Maldonado JR. Delirium in the acute care setting: Characteristics, diagnosis and treatment. Crit Care Clin. 2008. 24:657-722.

[3] Morita T, et al. Opioid rotation from morphine to fentanyl in delirious cancer patients: an open-label trial. J Pain Symptom Mngmt. 2005. 30(1)96–103.

Which of the following recommendations would be appropriate to share with the primary team to assist in the management of hypoactive delirium?

Select all that apply
Expand all answers
Promote sleep by keeping the patient’s room dark with minimal interruptions during the day
No! Promote a normal sleep-WAKE cycle by keeping the room bright with more interaction during the day. Then go ahead and minimize interruptions overnight.


Search for and treat any reversible medical issues, such as infection, dehydration, malnutrition, constipation, urinary retention, pain, or medications that might be contributing to her delirium.
Yes! This is a mainstay of delirium prevention and management.


Use restraints to maintain safety in case she becomes more active
No! This is less of an issue in hypoactive delirium, but can become problematic in hyperactive or mixed delirium. Minimize use of restraints, as well as any unnecessary lines or tubes. Use behavioral redirection as much as possible.


Request family to bring in hearing aids and glasses
Yes. If available, these sensory aids should be used during the day.


Assist in early mobilization with nursing and PT staff as tolerated
Yes. Keep her moving!


Querques J, et al. Postoperative delirium. J Amer Psych. 2008. 165(7)803-812.

Maldonado JR. Delirium in the acute care setting: Characteristics, diagnosis and treatment. Crit Care Clin. 2008. 24:657-722.

Which of the following medications should be avoided in our delirious, elderly patient?

Select all that apply
Expand all answers
Lorazepam
Yes, benzodiazepines are deliriogenic and should be avoided when possible. Even when treating alcohol withdrawal [1], recent data on benzodiazepine-sparing protocols support the use of gabapentin and other agents to safely manage withdrawal while minimizing the risk of delirium, which often results from the overuse of benzodiazepines in response to CIWA scores.


Prednisolone
Yes, steroids should be avoided when possible given their effects on mood as well as sleep.


Diphenhydramine
Yes, anticholinergic medications should be avoided when possible. This includes not only diphenhydramine (Benedryl) and other antihistamines, but also several other common medications with cardiovascular, central nervous system, gastrointestinal, antibiotic, immunosuppressive, and other uses that also have anticholinergic effects [2].


Quetiapine
Yes, the sedating and anti-cholinergic effects of this medication are undesirable. Other less sedating antipsychotic agents may be selected as pharmacologic therapy for hypoactive delirium, for which there is some evidence [2].


Hydromorphone
Yes, opioids should be avoided. But pain control is also important in the management of delirium, so if pain medications must be escalated to the level of opioids, hydromorphone is a reasonable choice. Hydromorphone and fentanyl have been shown to be less deliriogenic than other opioid formulations, including morphine [3].


[1] Maldonado JR. Novel algorithms for the prophylaxis and management of alcohol withdrawal syndromes—beyond benzodiazepines. Crit Care Clin. 2017. 33(3)559-599.

[2] Maldonado JR. Delirium in the acute care setting: Characteristics, diagnosis and treatment. Crit Care Clin. 2008. 24:657-722.

[3] Morita T, et al. Opioid rotation from morphine to fentanyl in delirious cancer patients: an open-label trial. J Pain Symptom Mngmt. 2005. 30(1)96–103.

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