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Before calling the psychiatric consultant, think of delirium
- Mimics many primary psychiatric disorders
- Prevalence about 20% on general medical units; 80% in ICUs
By definition caused by medical problems and/or medications
- Try using the Confusion Assessment Method (CAM)
Try the Mini-Cog!
Sorry about that, this video doesn’t seem to work in the slide set, but try the video below or the link in my comment below!
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Basic Delirium Management Recommendations
The first priority is to evaluate and manage the medical problems causing delirium.
Avoid Benzodiazepines and anticholinergic agents, such as TCAs, Benadryl, Hydroxyzine. Try to minimize exposure to opioids, which also can cause delirium.
Nonpharmacologic management for improving delirium includes the following critically important intervention:
1. Reorient the patient daily by keeping white board in room with correct date
2. Provide cognitive stimulation during the day
3. Improve sleep at night with non-pharmacologic methods if possible
4. Get the patient up and out of bed. Early mobilization is important, even if it means up to the chair.
5. Timely removal of catheters and physical restraints
6. If patient wears devices such as glasses, hearing aids etc. make sure the patient has them and uses them
7. Early correction of dehydration and encouraging good nutrition
8. Keeping unit quiet and minimizing noise as much as possible.
Basic Delirium Management Recommendations, cont.
There have been studies using dexmedetomidine in weaning ventilated patients showing reduction in agitation.
Dexmedetomidine was shown to be a “promising agent” for management of ICU-associated delirious agitation.
Monitoring Side Effects of Antipsychotic When Using it for Agitation:
- Continue to monitor EKG periodically with Haldol, which, particularly when given IV, may cause QTc prolongation. Others side effects include rigidity, cogwheeling, tremor, somnolence. Neuroleptic malignant syndrome is a medical emergency.
- If the patient receives Haldol IV, cardiac monitoring is needed.
- Monitor electrolytes, including magnesium and calcium, and TSH.
- The risk for QTc prolongation is not zero with other antipsychotics, including the atypicals. Atypical antipsychotics may increase the risk of mortality in the demented elderly.
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