Mgh Handbook Delirium

Front 1

basic features of delirium

Back 1

- altered consciousness with cognitive deficits not explained by past dementia
- impaired attention
- waxing and waning
- alternation of sleep- wake cycle

Front 2

do you see psychosis in delirium?

Back 2

- yes! they can appear very psychotic (paranoid patient accusing nurses of pornography)

Front 3

what is the hypoactive delirious patient often confused with?

Back 3

- depression or anxiety

Front 4

physiology behind delirium

Back 4

- hyperdopaminergia and hypocholinergia (thus anticholinergics are bad and old people with dementia and low cholinergics have increased risk of dementia)

Front 5

delirium assesssment tools

Back 5

- CAM
- Delirium rating scale (DRS)
- MDAS (memorial delirium assessment scale)

Front 6

important causes of delirium to think about in the ED

Back 6

- wernicke's, hypoxia, hypoglycemia, HTN encephalopathy, hyper/hypothermia ICH, meningitis, encaphlaitis, poisoning, status epilepticus
- aka WHHHHIMPS

Front 7

common conditions associated with delirium

Back 7

- I: infectious
- W: withdrawal
- A: Acute metabolic
- T: trauma
- C: CNS pathology
- H: Hypoxia
- D: deficiencies
- D: endocrinopathies
- A: acute vascular
- T: toxins or drugs
- H: Heavy metals

Front 8

drugs associated with delirium

Back 8

- antiarrhythmics, abx, anticholinergics, TCAs, AED, anti-HTN, antiviral, barbiturates, BB, H-blockers, digitalis, disulfiram, diuretics, DA agonists, ergotamine, GABA agonists, immunosuppressives, MAO-I, narcotics, NSAIDs, clozaril, lithium trazodone, mefloquine, sympathomimetics, steroids, ACTH

Front 9

neuro exam

Back 9

- eyes, pupils, nuchal rigidity, hyperreflexia (withdrawal), hung-up reflexes (myxedema), assymetric weakness, gait, babinski's reflexes, tetany, absent vibratory and position senses, hyperventilation

Front 10

frontal lobe function

Back 10

- grasp, snout, palmomental, suck, glabellar reasponses

Front 11

what does the luria sequence test?

Back 11

- premotor area (Brodmann's area)

Front 12

"Frank Jones Story"

Back 12

- I have a friend, Frank Jones, whose feet are so big he has to put his pants on over his head. How does that strike you?
- normal: sees incongruity and smiles (limbic response) and explains why it can't be done (neocortx)
- abnormal: patient smiles (limbic response) but can't explain
- abnormal: patient neither gets incongruity nor can explain impossibility

Front 13

most useful tool in delirium

Back 13

- EEG
- delirium: see generalized slowing in theta-delta range
- DTs: low-voltage fast activity superimposed on slow waves
- sedative-hypnotic toxicity: fast beta activity
- hepatic encephalopathy: triphasic waves

Front 14

psychosocial or environmental treatment

Back 14

- windows, calendars, clocks, mementos from home
- soft and low lighting at night
- family present
- reorient patient
- rarely effective

Front 15

reversal of benzos, narcotics, anticholinergic

Back 15

- flumazenil
- naloxone
- physostigmine --> SE: bradycardia, hypotension

Front 16

treating delirium vs treating sx of delirium

Back 16

- treat underlying cause vs using meds to treat symptoms

Front 17

tx of agitation in withdrawal (alcohol, benzos, barbiturates)

Back 17

- diazepam 2.5 to midazolam 0.5 to 1
- morphine
- careful in older patients

Front 18

benefits of haldol

Back 18

- milder effects on blood pressure, pulmonary artery pressure, heart rate, respiration

Front 19

which formulation of haldol has least EPS sx?

Back 19

- IV

Front 20

equivalencies of different forms of haldol?

Back 20

- po is half as potent as parental (IM or IV)

Front 21

what should haldol not be mixed with when given IV?

Back 21

- phenytoin and heparin
- must flush IV line prior to giving haldol, else it will precipitate

Front 22

dose of haldol for elderly

Back 22

0.5

Front 23

dose of haldol for non elderly

Back 23

- mild agitation: 2mg
- moderate agitation: 5 mg
- severe agitation: 10mg
- stagger doses by 30 min
- if 5mg fails after 30 min, given 10mg

Front 24

how to use haldol and ativan together

Back 24

- ativan is effective within 5-10 min, so precede haldol with ativan to observe impact on agitation and it can be increased if effective

Front 25

once treated for delirium, how do you protect from more episodes?

Back 25

- small doses (1-3mg) at night orally

Front 26

max doses of IV haldol

Back 26

- single bolus of 200mg
- more than 2000mg per 24 hours
- delirious patient with intra-aortic balloon pump
- also can do haldol infusion
- via protecting neurons from oxidative stress (max DA receptor blockade occurs at low dose haldol)

Front 27

ddx if haldol doesn't tx agitation?

Back 27

- is haldol producing akathisia?

Front 28

when to use haldol cautiously

Back 28

- baseline prolonged QTc
- hepatic compromise
- specific cardiac abnormality: mirtral prolpase, dilated ventricles

Front 29

when to worry about QTc

Back 29

- low K and Mg
- alcoholic liver disease

Front 30

which neuroleptic has potent alpha-blocking properties that can be dangerous for critically ill pts?

Back 30

- chlorpromazine

Front 31

which second generation antipsych has most data supporting use in delirium?

Back 31

- risperidone

Front 32

which neuroleptic has lowest increase in QTc?

Back 32

- haldol

Front 33

which neuroleptic to use in critically ill HIV pts?

Back 33

- molindone since they are more susceptible to EPS and NMS with haldol
- or chlorpromazine or perphenazine

Front 34

which neuroleptic to use in parkinson's

Back 34

- clozapine 6.25mg or 12.5mg
- quetiapine
- b/c of low affinity for dopamine receptors

Front 35

alcohol tx of alcohol w/d

Back 35

- extreme cases where high dose benzos do nothing
- 5% alcohol mixed with 5% dextrose in water run at 1ml per minute

Front 36

sedate critically ill patients

Back 36

- can use propofol
- careful with hypotension if bolus
- longer half life in elderly
- being emulsed in fat may cause problems: overfeeding, CO2 production, hyperTG, ketoacidosis, seizure 6 days after d/c