World Delirium Awareness Day is coming like a zombie–and delirium will eat your brain! In keeping with upcoming World Delirium Awareness Day March 14, 2018, here are some oldies but goodies along with a reminders about special cases of delirium. First, a pretty good video summary of the basics which you can access from the American Delirium Society website:
Secondly, a free video about how to use the Mini-Cog to screen delirium. This was made by a couple of excellent UIHC Psychiatry residents a few years ago.
You don’t have to use a pre-printed Mini-Cog form, although they are useful. I usually like them because the circle is nice and big, making it easier to see what the patient draws. The instructions are simple and can be on a laminated pocket card:
The other thing to be alert for is the catatonic variant of delirium, the management of which can sound counter-intuitive. It involves administering the IV lorazepam challenge test to break the spell of catatonic stupor. Usually we try to avoid benzodiazepines in delirious patients because they can cause delirium. The exceptions to avoiding benzodiazepines are then: catatonia and alcohol or sedative-hypnotic withdrawal, the latter of which can itself cause catatonia.
You can find out more about medical catatonia and delirium in the Psychiatric Times article “Update on Medical Catatonia: Highlight on Delirium,” by J. Wilson, L. Denysenko, and A. Francis. It looks like you can get access to this article without logging in, which you could not do last year. Maybe that’s because the site is under new management. In any case, if you can’t, registration is free.
And there’s a nice slide set you can modify to meet your organization’s needs, available from the NICE guidelines.
There is no good evidence that antipsychotics of any type treat delirium per se. That doesn’t mean we let patients suffer from relentless agitation, fragmented delusions, and terrifying hallucinations, all of which can themselves lower quality of life and shorten life as well. It means we need to have a thorough discussion with families about the risks and benefits of using any kind of psychotropic drugs in the setting of delirium, especially antipsychotics. For the most part, multi-component non-pharmacologic methods are recommended. Remember, delirium is a zombie. It’ll eat your brain.
Neufeld, K. J., Yue, J., Robinson, T. N., Inouye, S. K., & Needham, D. M. (2016). Antipsychotics for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta-analysis. Journal of the American Geriatrics Society, 64(4), 705–714. http://doi.org/10.1111/jgs.14076
Amos, J. J. (2012). “Lorazepam withdrawal-induced catatonia.” Ann Clin Psychiatry 24(2): 170-171.