The Use of Environmental Strategies and Psychotropic Medication in the Management of Delirium

Meagher, David; O'Hanlon, Donal; O’Mahony, Edmond; Casey, Patricia

doi:10.1192/bjp.168.4.512

Cited by 95 publications

(55 citation statements)

References 9 publications

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“…Other studies have also found mixed subtype as the most common. 23,24 It has been suggested that the subtypes differ in the underlying pathology, response to therapeutic intervention and outcome, with hypoactive delirium having a notably poorer prognosis although some studies have not found such an association. 25,26 Hypoactive delirium is likely to go undiagnosed thereby resulting in poorer prognosis.…”

Section: Discussionmentioning

confidence: 99%

Prevalence, phenomenology and etiology of delirium in medically ill patients

2016

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INTRODUCTIONDelirium is characterized by an acute decline in the level of consciousness and cognition with particular impairment in attention. Other associated features include abnormal psychomotor activity, sleep cycle impairment and psychiatric symptoms such as abnormalities of mood, perception and behaviour.1 It develops over a short period of time and fluctuates during the course of the day. It is a common neuro cognitive disorder which heralds an increase in morbidity and mortality.2 It is also known by other terms such as acute confusional state, toxic psychosis and metabolic encephalopathy. 1 Delirium is usually rapid in onset with a diurnally fluctuating course and duration of less than six months. Based on the etiology, DSM 5 classifies delirium as substance intoxication delirium, substance withdrawal delirium, medication-induced delirium, delirium due to another medical condition and delirium due to multiple etiologies.2 It is also further specified as hyperactive delirium, hypoactive delirium and mixed delirium based on the level of psychomotor activity.2,3 The cause of ABSTRACT Background: Delirium is one of the most common causes of referral of medically ill patients for psychiatric management and is associated with significant morbidity and mortality. The aim of the study was to determine the prevalence and etiology of delirium among medically ill patients and to describe its phenomenology. Methods: A cross-sectional descriptive study was conducted in the general medical ward of a tertiary care hospital. Four hundred patients were screened for delirium using the confusion assessment method. The delirium rating scale revised-98 was used to further characterize the severity and phenomenology of delirium. Descriptive statistics such as frequencies, means and standard deviation were used. Chi square test was applied to compare categorical variables and Fisher's exact test was used to test associations. Student t test was used to compare the means of independent groups. Results: The prevalence of delirium was 9.75%. Male gender (69.23%) and age above 60 years (66.67%) were significantly associated with delirium (p values of 0.04 and <0.001 respectively). Mixed delirium was the most common motor subtype (46.15%). The most common cause of delirium was metabolic encephalopathy (43.59%). There was significant association between hyperactive delirium and psychotic symptoms. Delirium went undiagnosed in 61.64% of the cases. Conclusions: Delirium is a common problem among medically ill patients and runs the risk of being undiagnosed. Clinicians should routinely screen patients at high risk for delirium to decrease the morbidity and mortality associated with this dreaded, yet potentially reversible entity.

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Section: Discussionmentioning

confidence: 99%

Prevalence, phenomenology and etiology of delirium in medically ill patients

2016

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“…Для больного должно быть создано адекватное окруже-ние, с минимальным числом смен палаты и место-положения, персонала, низкой освещенностью па-латы по ночам и минимальным уровнем шума. Только в ограниченном числе исследований изучал-ся вопрос об эффективности когнитивных, эмоцио-нальных и средовых вмешательств при лечении де-лирия [55][56][57][58], но такие вмешательства стали стан-дартными рекомендациями, базирующимися на клиническом опыте, здравом смысле и отсутствии побочных эффектов [59].…”

Section: нефармакологические стратегии леченияunclassified

Post stroke delirium

Ma¹

2014

Z. nevrol. psikhiatr. im. S.S. Korsakova

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“…66,111 Cognitive impairment in the context of a mild hypoactive subtype of delirium is more likely to be missed. 116 Cognitive screening of cancer patients with a briefly administered instrument such as the Minimental State Examination helps to detect cognitive deficits that otherwise might be missed. 3 This instrument has been widely used, and its psychometric properties are well known.…”

Section: Assessment Of Cognitive Dysfunction In Opioid-treated Patientsmentioning

confidence: 99%

“…• Educate family regarding nature of opioid-related cognitive dysfunction and delirium: psychomotor agitation, perceptual disturbance, delusions, and communication difficulties [107][108][109][110] • Establish goals of care, evaluate pros and cons of intervention in the context of the patient's clinical situation, previously expressed wishes, and family wishes 128 • Monitor delirium severity with an instrument that is either partly 118,119 or wholly observational 42,122,123 • Consider either opioid dose reduction or opioid switch [129][130][131][132][133] • Discontinue or minimize use of all unnecessary medications, especially other psychotropics 4 • Consider all other contributory causes, especially concurrent reversible causes 4 • Assess renal function and adjust dose of opioid or other drugs accordingly [92][93][94][95][96][97] • Assess hydration and supplement with parenteral fluids if necessary 4 • Commence symptomatic treatment of delirium with neuroleptic such as haloperidol 8,150,151 • Environmental manipulation: minimal noise, reorientation, encourage presence of family member 116 • Prevent recurrence: if delirium is reversed, address risk factors for recurrence in future (see Table 6) and emotional lability to be misinterpreted as poor pain control. 108,109 The use of psychostimulants has been advocated in the treatment of opioid-induced sedation, [157][158][159] and cognitive benefit has been demonstrated with neuropsychologic testing in a randomized, doubleblind, placebo-controlled, crossover trial of methylphenidate in patients receiving a continuous infusion of opi...…”

Section: Table 8 Proposed Management Approach To Patients Presenting mentioning

confidence: 99%

The panorama of opioid‐related cognitive dysfunction in patients with cancer

Lawlor

2002

Cancer

104

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BACKGROUNDOpioids have an essential role in the management of pain in cancer patients, particularly those with advanced disease. Cognitive dysfunction is a recognized complication of opioid use. However, misconceptions and controversy surround the nature and prevalence of its occurrence. A projected increase in the aging cancer population highlights the need for a better understanding of this phenomenon.METHODSA critical appraisal of the literature evidence in relation to the pattern, pathophysiology, assessment, impact, and management of cognitive dysfunction due to opioid use in cancer pain management is given.RESULTSStudies in cancer patients with less advanced disease reveal subtle evidence of cognitive impairment, largely related to initial dosing or dose increases. In advanced cancer, opioid‐induced cognitive dysfunction usually occurs in the form of delirium, a multifactorial syndrome. The presence of both cognitive impairment and delirium frequently is misdiagnosed or missed. Potential risk factors include neuropathic and incidental pain, opioid tolerance, somatization of psychologic distress, and a history of drug or alcohol abuse. Elevation of opioid metabolites with renal impairment may contribute to cognitive dysfunction. Recognition of opioid‐related cognitive dysfunction is improved by objective screening. Successful management requires either dose reduction or a change of opioid, in addition to addressing other reversible precipitants such as dehydration or volume depletion.CONCLUSIONSOpioid‐related cognitive dysfunction tends to be subtle in the earlier stages of cancer, whereas delirium, a more florid form with behavioral disturbance is likely to be present in the advanced cancer population. In patients with advanced disease, an optimal management approach requires careful clinical assessment, identification of risk factors, objective monitoring of cognition, maintenance of adequate hydration, and either dose reduction or switching to a different opioid. Cancer 2002;94:1836–53. © 2002 American Cancer Society.DOI 10.1002/cncr.10389

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The Use of Environmental Strategies and Psychotropic Medication in the Management of Delirium

Cited by 95 publications

References 9 publications

Prevalence, phenomenology and etiology of delirium in medically ill patients

Prevalence, phenomenology and etiology of delirium in medically ill patients

Post stroke delirium

The panorama of opioid‐related cognitive dysfunction in patients with cancer

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