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Attheconclusionofthispsychopharmacologyseminar,theparticipantwillbeableto:•  Describethebestpracticesinassessing,

diagnosing,andselectingmedicationstotreatdepression,anxiety,psychosisandinsomnia.

•  Describethemostcommondrug/drug,drug/diseaseanddrug/dietinteractionswiththemostcommonlyusedpsychopharmacologyagents.

•  Givenasimulatedcaseofapatientwithamentalhealthcomorbidcondition,demonstratehowtoprovidemedicationcounselling,includingthethreemostcommonadverseeffectsassociatedwiththerapyandactionstepsshouldtheyoccur.

2

LearningObjectives

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Isitpain,orpsychosocial?

•  Comprehensivepsychosocialpainassessmentforaninterdisciplinarypainservice.

•  Impactofunrelievedpainonthepatient/familyexperienceinthefollowingfivedomains:•  Economic•  SocialSupport•  ActivitiesofDailyLiving•  EmotionalImpact•  CopingStyle

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7

Anxiety

Whatisanxiety?

8

SymptomsofAnxiety

•  Trembling,feelingshaky,restlessness,muscletension•  Shortnessofbreath,smoothingsensation•  Tachycardia(rapidheartbeat)•  Sweatingandcoldhandsandfeet•  Lightheadednessanddizziness•  Paresthesias(tinglingoftheskin)• Diarrheaand/orfrequenturination•  Feelingsofunreality(derealization)•  Initialinsomnia(difficultyfallingasleep)•  Impairedattentionandconcentration• Nervousness,edginess,ortension

9

SIXmajortypesofanxietysyndromes

•  GeneralizedAnxietyDisorder•  Stress-RelatedAnxiety•  PanicDisorder•  SocialAnxiety•  MedicalIllnesses,andMedicationsPresentingwithAnxietySymptoms

•  AnxietyasPartofaPrimaryMentalDisorder

Sixanxietysyndromes

Syndrome Description

GeneralizedAnxietyDisorder •  Thekeyhereislong-term,low-level,fairlycontinuousanxiety.•  PatientswiththisdisorderMAYhavenospecificcurrentlifestressors.•  Tothem,dailylivingprovokesanxiety.•  Suchpeoplearechronicworriers,always“what-if-ing”(e.g.,“WhatifIget

fired?”;“Whatifmycheckbounces?”;“Whatifmywifeleavesme?”

Stress-relatedAnxiety •  Thepatientwiththisdisordertypicallyfunctionswell.•  However,theanxietysymptomshaverecentlyemergedinthefaceofmajor

lifestresses(e.g.,aseriousfamilyillness,amaritalseparation,etc.)

PanicDisorder •  Thisischaracterizedbyrepeatedepisodesoffull-blownpanic.•  Oftenphobiaswillalsodevelop.

SocialAnxiety •  Anxietyisexperiencedonlywhenthepersonisinsocial/interpersonalsettings(e.g.,publicspeaking,askingsomeoneoutforadate,socialgatherings)

11

Sixanxietysyndromes

Syndrome Description

MedicalIllnesses,andMedicationsPresentingwithAnxietySymptoms

•  Certaindiseases/conditionscanattimesresultinbiochemicalchangesthatproduceanxietysymptoms.

•  Ifsomeonecomplainsofnervousnessoranxiety,ifshouldneverbeassumedthatitissimplyanemotionaldisorderuntilmedicalcauseshavebeenruledout.

•  Likewise,anumberofmedicationsandover-the-counterproductscancausepronouncedanxietysymptoms.

AnxietyasPartofaPrimaryMentalDisorders

•  Anxietyfrequentlyaccompaniesmanymentaldisorders(e.g.,depression,schizophrenia,organicbrainsyndromes,substanceabuse)

12

Commondisordersthatcancauseanxiety• Adrenaltumor• Alcoholism• Anginapectoris•  Cardiacarrhythmias•  CNSdegenerativediseases•  Cushing’sdisease•  Coronaryinsufficiency• Delirium• Hypoglycemia

• Hyperthyroidism• Meniere’sdisease(earlystages)

• Mitralvalveprolapse•  Parathyroiddisease•  Partial-complexseizures•  Post-concussionsyndrome•  Premenstrualsyndrome

13

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PainAttacksvs.Anxiety

•  Panicattacks–verybriefbutextremelyintensesurgesofanxiety.

• Differencesareintheonset,durationandintensityofsymptoms.

15

Variable PanicAttack Anxiety

Onset “Comeoutoftheblue”(notnecessarilyprovokedbystress) Canbeunpleasant,butmuchlessintense.Canbeprolongedorgeneralized(presentmostofthedayandlastsdaystoyears).

Theycomeonsuddenly–fullattackreachingitspeakinfrom1-10minutes

Intensity Extremelyintense

Duration Last1-30minutes,thensubside

Sensation Patientfeelsasiftheywillactuallydieorgocrazy

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SymptomsofAnxiety

•  Trembling,feelingshaky,restlessness,muscletension•  Shortnessofbreath,smoothingsensation•  Tachycardia(rapidheartbeat)•  Sweatingandcoldhandsandfeet•  Lightheadednessanddizziness•  Paresthesias(tinglingoftheskin)• Diarrheaand/orfrequenturination•  Feelingsofunreality(derealization)•  Initialinsomnia(difficultyfallingasleep)•  Impairedattentionandconcentration• Nervousness,edginess,ortension

18

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AntianxietyMedications

• Buspirone–slowacting(2-6weeksoftreatmentbeforesymptomaticimprovement)•  Patientsoftenprematurelydiscontinuetherapy,expectingquickresults•  Doesn’ttreatpanicattacks•  Mustbetakendaily;nota“prn”medication

•  PregabalinnotFDAapprovedforanxiety• Gabapentinmayalsobeanoption(notFDAapproved)

22

AnxietyDisorder Generic Brand UsualDailyDosageRange

GeneralizedAnxietyDisorder

Buspirone BuSpar 5-40mg

Pregabalin Lyrica 25-450mg



Stress-RelatedAnxiety Diazepam Valium 5-40mg

Chlordiazepoxide Librium 15-100mg

Lorazepam Ativan 2-6mg

Alprazolam Xanax 0.25-4mg

Hydroxyzine Atarax,Vistaril 10-50mg

Clonazepam Klonopin 0.5-4mg

23


• Othermedications:•  Gabapentin(Neurontin)•  SSRIantidepressants•  SNRIantidepressants•  Neurolepticssuchashaloperidol(Haldol)orquetiapine(Seroquel)•  Sedativehypnoticsforanxiety-associatedinsomnia•  Antihistamines(diphenhydramine[Benadryl])

24


PanicDisorder Alprazolam Xanax 0.25-8mg

Lorazepam Ativan 2-6mg

Clonazepam Klonopin 0.5-4mg

SocialPhobia Propranolol Inderal 20-80mg

25

Depression

MajorClinicalFeaturesandDifferentialDiagnosisinDepression

•  Fivedifferentsyndromes:•  Reactivesadness•  Grief•  Medicalillnessandmedicationsthatcancausedepression

•  Clinicaldepression•  Dysthymia(PersistentDepressiveDisorder)

5Syndromes

• Reactivesadness•  Theemotionalreactionstemsfromarelativelyminorevent.•  Itistransient(afewhourstoafewdays)andrarelyinterfereswithfunctioning

• Grief•  Normalresponsetoamajorinterpersonalloss(deathofalovedone,maritalseparation/divorce)

•  Canbetremendouslypainfulandmuchmoreprolongedthanreactivesadness

•  Canlastmonthsorpersistforseveralyears

27

Griefvs.ClinicalDepression

• Despiteintensesadness,thereisnosignificantlossofself-esteem

• Markersthatgriefhasdevelopedintoclinicaldepressioninclude:severesleepdisturbances(especiallyearlymorningawakening),apervasivelossofinterestinnormallifeactivities,significantagitation,and/orsuicidalideations

•  Thepatientclearlyrelatesthesadnesstotheloss.Theremaybeactivemorningandpiningforthelovedone;thepainfulfeelings“makesense”

28

Griefvs.ClinicalDepression

• Griefwork(e.g.,mourning)andtimeareoftenthemajoringredientsnecessaryforemotionalhealing

• Atleast25%ofpeopleexperiencingamajorlosswillinitiallyexhibitgriefreaction,butduringtheyearfollowingthelosswillgoontodevelopmajordepression.

• Additionally,10%ofbereavedindividualswilldeveloptraumaticstresssymptomsfollowinginterpersonallosses(e.g.,intenseanxiety,nightmares).

29

5Syndromes–CommonIllnessesthatCauseDepression•  Addison’sdisease•  AIDS•  Alzheimer’sdisease

•  Anemia

•  Apnea•  Asthma

•  Chronicfatiguesyndromes

•  Chronicinfection(mononucleosis,TB)

•  Chronicpain•  Congestiveheartfailure

•  Cushing’sdisease•  Diabetes•  Hyperthyroidism

•  Hypothyroidism

•  InfectiousHepatitis•  Influenza•  Lymedisease

•  Malignancies(cancer)

•  Malnutrition

•  Menopause

•  Multiplesclerosis

•  Parkinson’sdisease•  Post-partumhormonal

changes

•  Porphyria•  Premenstrualsyndrome

•  Restlesslegs•  Rheumatoidarthritis

•  Sleepapnea•  Syphilis•  Systemiclupuserythematosus

•  Ulcerativecolitis

•  Uremia

30

5Syndromes–Drugsthatmaycausedepression

Type Name

Antihypertensives Reserpine(Serpasil),propranolol(Inderal),methyldopa(Aldomet),guanethidine(Ismelin),clonidine(Catapres),hydralazine(Apresoline)

CorticosteroidsandHormones

Cortisone(Cortone),estrogen(Femest),progesterone(Progestasert),prednisone,dexamethasone(Decadron)

Antiparkinson’sdrugs

Levodopa/carbidopa(Sinemet),amantadine(Symmetrel)

Antianxietydrugs Alprazolam(Xanax),diazepam(Valium),lorazepam(Ativan)

Birthcontrolpills Progesterone,estrogen

Alcohol Wine,beer,spirits

Antivirals Interferon(Interon-A),ribavirin

Dermatologicals Isotretinoin

Gastrointestinal Metoclopramide(Reglan)

31Addafooter

5Syndromes–ClinicalDepression(pathologicalprocess)• Depressedmood(sadnessoremptiness)orirritabilityisoftencontinuousandpervasive

• Alossofinterestinnormallifeactivities•  Thereisincreasingimpairmentofnormalfunctioning(work,school,andintimaterelationships)

•  Thereinirrationalorexaggeratederosionofself-esteem•  Thereisadramaticandspecificchangeinvegetativepatterns(e.g.,sleep,appetite,sexdrive,etc.)andtheappearanceofnonspecificphysicalcomplaints

• Depressioncanoccurinresponsetopsychologicalstressors,ormayemergewithoutclear-cutprecipitatingevents

32

Barrierstorecognizingdepression(oranxiety)

•  Theclinician’sownlackofknowledgeorskilltodiagnoseandtreatdepressionoranxiety

• Reluctancetobringuppotentiallyupsettingtopics(averylowproportionofpatientsdiscusstheirlowmoodwiththeirdoctorsoroncologistsandchoosetoaddresssomaticratherthanaffectiveandemotionalsymptoms)

• Beliefthatdepressionis“normal”attheendoflife•  Concernsaboutpossibledrug-druginteractionswithantidepressants

33

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Medication Sideeffectstoconsider Comments

Serotoninreuptakeinhibitors(SSRIs)

•  GIdisturbances(nausea,diarrhea)•  Sexualsideeffects(decreasedlibido,delayedorgasm)•  Increasedanxietyorrestlessness,especiallyearlyin

treatment•  Headache•  Insomnia/somnolence

•  Fullbenefitin4-8weeks

Fluoxetine(Prozac) •  UsuallyadministeredintheAM•  LongestactingSSRIagent,doesnotrequiregradual

discontinuation

Sertraline(Zoloft) UsuallyadministeredintheAM

Citalopram(Celexa)Escitalopram(Lexapro)

•  Maybeeitheractivatingorsedating(AMorPMadmin)

•  QTcmonitoringwarrantedforatriskpatients

Paroxetine(Paxil) •  ShortestactingSSRI;gradualdiscontinuationrecommended,otherwiseunpleasantdiscontinuationsyndrome(flu-likesymptomsoccurringwithin2-7daysofstoppinganSSRI)mayoccur.

•  TendstobesedatingandadministeredinPM36


Serotonin-norepinephrinereuptakeinhibitors(SNRIs)

•  GIdisturbances(nausea,diarrhea)•  Sexualsideeffects(decreasedlibido,delayedorgasm)•  Drymouth•  Constipation•  Urinaryretention•  Treatment-emergenthypertension

•  Oftenfirst-lineagentsforpatientswhohavecomorbiditiessuchaspain,neuropathy,orstressincontinence

Venlafaxine(Effexor) •  Canbebeneficialfortreatmentofvasomotorsymptomsofmenopause.

•  Discontinuationsyndromecommonwhenstoppedabruptly.

Duloxetine(Cymbalta) Hepatotoxicityinpatientswithpre-existingliverdisease

•  Approvedfortreatmentoffibromyalgiaaswell.•  Discontinuationsyndromecommonwhenstopped

37


Otherantidepressants

Mirtazapine(Remeron) Drymouth,sedation,weightgainLimitedsexualsideeffects

•  Sedating,appetite-stimulating,administeredatnight•  Anti-nauseatreatmentinchemotherapy•  Solu-tabformulationavailable•  Maybeusedtoaugmentotherantidepressants

(e.g.,addsedatingorappetite-stimulatingeffect)

Bupropion(Wellbutrin,Zyban)

Insomnia,drymouth,tremor •  Indicatedfortreatmentofdepressionbutnoteffectiveforanxietydisorders

•  Maybeusefulinfatiguedorlethargicpatients•  Alsoindicatedforsmokingcessation•  Safeindepressedcardiacpatients

Methylphenidate(Ritalin),Dextroamphetamine

Anxiety,insomnia,tachycardia,moodinstability.Athigherdoses:nightmares,insomnia,tics,paranoia

•  Usefulindepressedpatientsattheendoflifetohelpimprovetheirmood,wakefulnessandenergymoreimmediately.

•  Maypotentiatetheanalgesiceffectofopioidanalgesicsandcounteractopioid-inducedsedation

Modafinil(Provigil) Headache,anxiety,insomnia,hypertension,palpitations,drymouth,diarrhea,nausea,anorexia

•  Possiblysaferforpatientswithahistoryofseizuresorcardiacarrhythmia

38

SpecialProblemsandMedicationSelection

TheProblem MedicationConsiderations

Highsuiciderisk AvoidtricylicsandMAOIs

ConcurrentdepressionandpanicattacksorOCD SSRIs

Chronicpainwithorwithoutdepression Amitriptyline,nortriptyline,venlafaxine,duloxetine

Weightgainonotherantidepressants Bupropion,SSRIs,avoidmirtazapine

Sensitivitytoanticholinergicsideeffects Avoidtricyclicsandparoxetine

Orthostatichypotension Nortriptyline,bupropion,sertraline

Sexualdysfunction Bupropion,nefazodone

Anorexia/failuretothrive Mirtazapine

Druginteractions Sertraline,citalopram

Problematicwithdrawaleffects Recommendgradualwithdrawal.Consideravoidingvenlafaxineandparoxetine

39

6-%$(&%;)&3&*3(-0&

d_%

•  CW,a50-year-olddivorcedmotherof2growndaughters,hasmetastaticovariancancer,nowrecurringforathirdtime.

•  Recentchemotherapyhasreducedhertumorburden.Whatremainsimpingesonhersacralplexus,causingpainthatcanbecontrolledonlywithhighdosesofopioids.

•  Evenwiththesehighdoses,shereportsdailypainintherangeof6to8ona10-pointscale.

•  Beforethisrecurrence,herexcitingjobgaveherasenseofpurpose.•  CWhasbeeninpsychotherapyformanyyearsandhashad2brieftrialsofantidepressantmedicationthatshedidnotfindhelpful.

•  Sincehersecondrecurrence,shehashadamajordepressionthathasbeendifficulttotreat.

•  Shewakesearly. 41

•  Herappetiteispoor,andshehaslostweight.•  Inreviewingherlife,shesays,“I'mnotsurewhyI'vebeenalive.”•  Althoughheroncologistthinksthatshehasmanymonthsofgood-qualitylifeaheadofher,CWtalksaboutdeathasifitisimminentandwelcome.

•  Sherarelymentionsthefriendswhostopbyandsaysshedoesnotenjoytheirvisits.

•  Shelooksforwardtonothing,butdeniessuicidalwishes.•  Heroncologisthassuggestedanotherroundofchemotherapy,expectingthatitwilleithershrinkherremainingdiseaseor,atleast,sustainhercurrentstate.

•  CWsaysshedoesnotwanttofeelsickandloseherhairagain.•  Sherefusestreatment,knowingthatherdecisionwillshortenherlife.•  Howshouldtheteamrespondtoapatient’srequesttodiscontinuelife-sustainingtreatment? 42

• ApainmanagementspecialistadjustedCW'smedication,andafter2weeks,shereportedherdailypainas3to4onascaleof10.

•  Sherefusedfurtheradjustment,fearingthathercloudedthinkingwouldrecur.

• Asubsequentnerveblockfurtherreducedherpain.ImprovedpaincontrolanddecreaseddrowsinessallowedCWtoconsideratriptovisitfriendsoutofstatebutdidnotchangeherdecisiontostopchemotherapy.

•  CouldCWbesufferingfromdepression?

43

•  CWfeelsdespairregardingherownlifeandfeelsresponsibleforthelivesherdaughterslead.

•  Shedoesnotenjoyfriendsorlookforwardtopleasuresstillavailabletoher.

• Herpsychologicalsymptomsofhopelessness,guilt,andlackofenjoymentindicateadiagnosisofdepression.

• Howshoulddepressionbetreatedinapatientwithterminalillness?

44

•  CWacceptedtreatmentwithsertralinehydrochloride.After5weeks,althoughfrequentlysad,shetookatriptovisitfriends.

•  Butshecontinuedtodescribeherlifeingloballynegativetermsandtorefusefurtherchemotherapy.

•  CouldtherebeotherissuesthatweneedtoaddresswithCW?Thoughts?

45

•  CWfeelsthatshehasfailedasaparent.•  Sheisangryanddisappointedthatheryoungerdaughterisunresponsivetoherincreasingneedforfinancialandemotionalsupport.

•  IndividualandfamilycounselinghelpedCWtobeclearandmorerealisticaboutherwishesforsupportfromandintimacywithherdaughter.

46

•  CWandherphysicianshavedonewhatispossibleinthewayofsymptomcontrol;diagnosisandtreatmentofdepression;andassessmentandtreatmentofspiritual,financial,andinterpersonalconcerns.

•  CWremainsdepressed.Canshemakeherowndecision?•  CW'sphysiciansmustnavigatebetweenprotectingherfromharmfulconsequencesofherdecisionandallowinghertocontrolhowherlifewillend.

• Refusingchemotherapycanbeexpectedtoshortenherlife.However,chemotherapyhasitsownburdensandisnotinthiscasecurative.

• DoesCWhavedecision-makingcapacity? 47

•  CWunderstandsthatinchoosingchemotherapy,shemaygaintimeandhavelesspain,butshewillalsoloseherhair,risknausea,andbefatigued.

•  Sheunderstandsthatshecanchoosetocontinuetreatmentatanytimeinthefuture,butbythen,herdiseasemayhavefurtherprogressed.

•  Throughmuchofherlife,thispatienthasgainedasenseofworthfromherabilitytohandledifficultiesonherown,andillnesshasbeen,forher,anexperienceofhelplessness,insignificance,anddependency.

•  Shehasstruggledwithdepressionfordecadesandisawareofthewaysinwhichmoodinfluencesherperceptions.

48

•  IndecidingthatCW'schoiceshouldberespected,herpsychiatristreasonedthatthepatient'sdecisionisconsistentwithherlong-termvaluesinwhichself-determinationiscentralandthatitisreasonablyinaccordwithherwell-being,althoughherdecisionmightnotmaximizeherlengthoflife.

• Depressionisinfluencingherdecisionwithoutmakingherincompetenttodecide.

• Whatistheroleofsafeguardsinevaluatingrequeststodiscontinuelife-sustainingtreatment?

49

•  Incontrast,shefeelsshehasfailedasamother.• Herolderdaughterhasahistoryofdrugabuseandhasfailedmultipledetoxificationprograms.

• Heryoungerdaughterquitcollegewithoutgraduating.• Neitherdaughterhasaconsistentrelationshipwithhermother.•  CWhaslivedalonesinceherhusbandlefther10yearsago.• Heroccasionalrelationshipswithmenhavenotlasted,butshehasmanyloyalfriends.

50

51

Delirium

AgitationandDelirium:They’ll Make You Crazy!

Learning Objectives: •! Identify the type of delirium

based upon presenting signs and symptoms.

•! Identify patient-specific risk

factors and medications contributing to or causing the patient’s symptoms.

•! Recommend a safe and effective management plan that addresses predisposing or precipitating factors.

the patient’s symptoms.

Recommend a safe and effective management plan that addresses predisposing or precipitating factors.

Inyourpractice,whatpercentageofpatientsdevelopdeliriumduringthelastweekoflife?

a)  0-25%b)  25-50%c)  50-75%d)  75-100%

)#+9";+'(+%-6%<+;8#8B/%<B#8'?%;",:%D++J%-6%;86+G%RSKSTU%

Casarett 2001

54%ofpatientsrecallexperienceafter

recovery

80%rateddeliriumexperienceas

severelydistressing

Breitbart 2002

Caregivers and patients experience high levels of distress during

episodes of delirium.

Breitbart 2002; Morita 2004; Morita 2007

Deliriumisfrequentlyunderrecognizedandundertreated.

Meagher 2001

Depression

Anxiety

Agitation Delirium

TheDeliriousPatient•  Disturbanceof:

•  Consciousness•  Attention•  Cognition•  Sleep-wakecycle•  Emotion

•  Developsovershortperiod(hourstoday)•  Fluctuatesduringtheday

Trzepacz 1999

Delirium:DSMIVCriteriaA.  Disturbanceofconsciousnesswithreducedabilitytofocus,sustain,orshiftattention.

B.  Changeincognitionordevelopmentofperceptualdisturbancethatisnotbetteraccountedforbyapreexisting,establishedorevolvingdementia.

C.  Disturbancedevelopsovershortperiod(hourstodays);tendstofluctuateduringtheday

D.  Evidencethatdisturbanceiscausedbydirectphysiologicalconsequencesofgeneralmedicalcondition.

APA 2000

Sundowning

•  “SundowningSyndrome”or“NocturnalDelirium”•  Disruptivebehaviorsatnightfallorsunset•  RiskFactors:

•  Circadianrhythmabnormalities•  Disruptionsinenvironment

Kim P, 2005

DistinguishingFeatures

DELIRIUM Dementia Depression Psychosis

Onset Acute Insidious Variable Variable

Course Quick, Fluctuating

Slow, progressive

Variable Variable

Reversibility Sometimes Non-reversible Reversible Variable

Consciousness/ Orientation

Disoriented Lucid until advanced

Normal Intact, may be confused

Attention Constant inattention

Attentive Poor attention

Poor attention

Memory Poor short-term

Poor short-term Intact Intact

IWATCHDEATHmneumonicLETTER DEFINITION CAUSES

I Infection UTI,encephalitis,meningitis,pus,skin/softtissue,pneumonia,HIV

W Withdrawal Alcohol,barbiturates,BZDs,sedatives,illicitdrugs

A Acutemetabolicdisorder Electrolyteimbalance,hepaticorrenalfx,alteredpH,hyper/hyponatremia,hyper/hypocalcemia

T Trauma Headinjury,subduralhematoma

C CNSpathology Stroke,hemorrhage,tumor,ictal/postictalstates

H Hypoxia Anemia,cardiacfailure,pulmonaryembolus

D Deficiencies VitaminB12,folicacid,thiamine,niacin

E Endocrinopathies Hypo/hyperthyroid,hypo/hyperglycemia,hypo/hypercortisol

A Acutevascular Shock,septichypotension,vasculitis,hypertensiveencephalopathy

T Toxins,substanceuse,meds Alcohol,anesthetics,BZDs,anticholinergics,narcotics,corticosteroids

H Heavymetals Arsenic,lead,mercury

Addafooter 64

DELIRIUMSmneumonicLETTER DEFINITIONANDCAUSES

D Drugs,dehydration,detoxification,deficiencies,discomfort(pain)

E Electrolytes,eliminationofabnormalities,environment

L Lungs(hypoxia),liver(hepaticfailure),lackofsleep,longemergencydepartmentstay

I Infection,iatrogenicevents,infarction(cardiac,cerebral)

R Restraints,restrictedmovement/mobility,renalfailure

I Injury,impairedsensoryinput(doesn’thaveglasses,hearingaids,dentures),intoxication

U Urinarytractinfection,unfamiliarenvironment/people

M Metabolicabnormalities(glucose,thyroid,cortisol,poornutritionalstatus),metastasis(brain),medications(anesthetics,BZDs,anticholinergics,narcotics,corticosteroids)

S Subduralhematoma

Addafooter 65

!-47;7/>Y&';"="(-<&'3%+"=+)(7"4"?)&

Cholinergic Function

Dopamine Release

Thalamus

Basal Ganglia

Frontal Cortex

/ Serotonin

Temporal-Occipital Cortex

Caraceni 2009

Diagnostic/ScreeningTools

Tool Use Mini-Mental State Exam Assesses general cognition, not

specific for delirium Confusion Assessment Method

Based on DSM-IV, detects symptoms of delirium

Agitated Behavior Scale Measures degree that agitation interferes with normal behavior

Memorial Delirium Assessment Scale

Measures severity of delirium

Delirium Rating Scale Includes a broader range of symptoms – used in research

ConfusionAssessmentMethod(CAM)RequiresBOTHAandB:

A. Acuteonsetandfluctuatingcourse•  Isthereevidenceofanacutechangeinmentalstatusfrompatientbaseline?•  Doestheabnormalbehavior:

•  Comeandgo?•  Fluctuateduringtheday?•  Increase/decreaseinseverity?

B. Inattention•  Doesthepatient:

•  Havedifficultyfocusingattention?•  Becomeeasilydistracted?•  Havedifficultykeepingtrackofwhatissaid?

www.viha.ca/mhas/resources/delirium

ConfusionAssessmentMethod(CAM)ANDeitherCorD:

C. Disorganizedthinking•  Isthepatient’sthinkingdisorganizedorincoherent?

•  Ramblingspeech/irrelevantconversation?•  Unpredictableswitchingofsubjects?•  Unclearorillogicalflowofideas?

D. Alteredlevelofconsciousness•  Overall,isthepatient’slevelofconsciousness:

•  Alert(normal)•  Vigilant(hyper-alert)•  Lethargic(drowsybuteasilyroused)•  Stuporous(difficulttorouse)•  Comatose(unrousable)

www.viha.ca/mhas/resources/delirium

BedsideConfusionScale

I. Assess level of alertness Normal = 0 Hyperactive = 1 Hypoactive = 1

II. Test of attention – a timed recitation of the month of the year in reverse order

Delay > 30 seconds – add 1 1 omission – add 1 2 omissions – add 2 >3 omissions, reversal of task or termination of task – add 3 Inability to perform – add 4

Total scores from section I and II Normal = 0; Borderline = 1; Diagnostic of confusion = 2-5 points

Sarhill N, Walsh D, Helson KA, et al. Am J Hospice and Pall Care 2001;18(5):335-341. Stillman MJ, Rybicki LA. J Pall Medicine 2000;3(4):449-456.

Doyouroutinelyscreenyourpatientsfordelirium?

a)  Yesb)  Noc)  Notsure

Whenyouscreeningpatientsfordelirium,whichtooldoyouuse?

a)  Mini-mentalStateExamb)  ConfusionAssessmentMethodc)  AgitatedBehavioralScaled)  MemorialDeliriumAssessmentScalee)  DeliriumRatingScalef)  BedsideConfusionScale

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