Diphenhydramine-induced delirium in elderly hospitalized patients with mild dementia

Hot, blind, and mad: avoidable geriatric anticholinergic delirium

The elderly are particularly sensitive to delirium-inducing medications. We report a case of a 93-year-old woman who developed anticholinergic delirium from subcutaneous diphenhydramine that she received in the emergency department. This patient was reportedly allergic to “caine” anesthetic agents, and thus, subcutaneous diphenhydramine was administered as an alternative local anesthetic, as recommended in emergency medicine textbooks. Within 20 minutes of administration, the patient developed agitation, tachycardia, dilated pupils, and dry skin, consistent with a classic anticholinergic toxidrome. Diphenhydramine use is associated with a high incidence of anticholinergic adverse effects, especially in the elderly. Clinicians should carefully consider using diphenhydramine in this vulnerable population.

Neurocognitive costs and benefits of psychotropic medications in older adults

Psychotropic medications are widely used in older adults and may cause neurocognitive deficits. Older adults are at increased risk of developing adverse effects because of age-related pharmacodynamic and pharmacokinetic changes. This article provides a comprehensive review of the undesirable, and at times beneficial, effects of psychotropic medications. The review covers a wide range of medications that impair executive function, memory, and attention, as well as a much smaller group of medications that lead to improved neurocognitive function. Some of the most commonly used psychotropic medications in older adults, namely, antidepressants, sedatives, and hypnotics, are among the drugs that most consistently lead to cognitive impairments. Medications with anticholinergic properties almost invariably lead to neurocognitive dysfunction, despite symptom improvement. The neurocognitive costs and benefits of psychiatric medications should be considered in the context of disease treatment in older adults.

Atypical antipsychotics in the management of delirium: a review of the empirical literature

OBJECTIVES

To review the existing literature of atypical antipsychotics in the treatment of delirium and make recommendations regarding their use in the treatment of delirium.

METHODS

I conducted a literature search in Pubmed, Psychlit, and Embase for studies using atypical antipsychotics in the treatment of delirium. In the absence of studies, case reports were used.

RESULTS

Overall 13 studies examined the use of risperidone, olanzapine, and quetiapine, two cases were reported about ziprasidone, and no publication was found using aripiprazole in the treatment of delirium. Among the existing studies were retrospective and prospective, open label studies in addition to one with a double blind design using risperidone. Risperidone, olanzapine, and quetiapine may be all similarly effective in the treatment of delirium, whereas there may be limited efficacy in the use of olanzapine in the hypoactive subtype of delirium in elderly populations, which may generalize to the other atypical antipsychotics. The use of atypical antipsychotics in the treatment of delirium is safe and carries a low burden of side effects.

SIGNIFICANCE OF RESULTS

Although atypical antipsychotics are widely used in the treatment of delirium, well-designed studies do not exist. Among the existing studies, stronger data supports the use of risperidone and olanzapine, and also quetiapine may be considered in the treatment of delirium. Recommendations are made based on the existing data and literature. The need for well-designed studies to validate the use of atypical antipsychotics in the treatment of delirium continues.

How Do Delirium and Dementia Increase Length of Stay of Elderly General Medical Inpatients?

The purpose of this study was to identify the proximate causes through which dementia and delirium extend length of stay (LOS) in elderly general hospital patients. Among 93 patients age >/=65 years admitted to a tertiary-care teaching hospital through the emergency department, admission ratings of cognitive impairment, delirium, and dementia predicted the emergence of mental and behavioral manifestations of delirium and dementia in the hospital and greater LOS. Mental and behavioral manifestations also predicted greater LOS. On average, mental manifestations appeared first and were followed by behavioral manifestations, and the appearance of both types of manifestations occurred before the mean LOS. The results suggest that elderly patients with dementia and/or delirium who become symptomatic after admission to a general hospital first show mental signs and symptoms, then show behavioral disturbances, which appear to be the proximate causes of greater LOS.

Managing delirium and agitation in elderly hospitalized orthopaedic patients: Part I--Theoretical aspects

Managing behavioral disorders such as delirium and agitation while simultaneously attending to the acute needs of elderly patients is a challenge that confronts orthopaedic nurses on a daily basis. This will only increase in frequency and complexity as the new century dawns. Delirium and agitation affect morbidity, mortality, length of stay, and costs--in short, outcomes. To manage and care for these patients, orthopaedic nurses must first update their knowledge of acute disorders that can disrupt mental status and behavior, and the effects of systemic events on brain function. With the knowledge of the pathophysiology of delirium and agitation, nurses then need to refine their assessment and intervention skills. This article describes the phenomena of agitation and delirium in the elderly acute orthopaedic patient, outlines current perceptions regarding pathophysiology, and offers guidelines for prevention and intervention. An algorithm has been developed that can assist with the identification of at-risk individuals, causes of delirium, and early assessments in the acute care setting.

Sedative-hypnotic use and increased hospital stay and costs in older people

OBJECTIVE

To assess the relationship between sedative-hypnotic (S/H) utilization, severity of illness, length of stay, and hospital costs among older patients admitted to a tertiary care university hospital.

DESIGN

Retrospective review of computerized hospital and pharmacy data bases.

SUBJECTS

A total of 856 older consecutive medical and surgical admissions from November 1993 to March 1994.

MEASUREMENTS

Sedative/hypnotic utilization in accord with the Health Care Financing Administration (HCFA) guidelines for S/H use in nursing homes. Jefferson Disease Staging to estimate severity of illness. Hospital records to obtain demographic characteristics, length of stay, and hospital costs.

RESULTS

Patients whose S/H use exceeded HCFA guide lines, compared with those within the guidelines and those receiving no drugs, had longer lengths of stay (21.5 days vs 12.3 days vs 6.7 days, P < .001), increased hospital costs ($29,245 vs $15,219 vs $7,516, P < .001). and greater severity of illness (245.8 vs 189.5 vs 148.5, P < .001). S/H use exceeding and within HCFA guidelines were associated with increased length of stay (both P < .0001) and hospital costs (both P < .0001).

CONCLUSIONS

Older hospitalized patients receiving S/H have greater severity of illness, longer lengths of stay, and higher hospital costs compared with other patients. S/H use, and, in particular, S/H use exceeding the HCFA guidelines, are associated with increased hospital stay and cost.

Drug-induced delirium. Incidence, management and prevention

Drugs may be the most frequent single cause of delirium, and very often they are a critical element in a multifactorial aetiology. While delirium may be precipitated by virtually any drug, certain classes of drugs are more commonly implicated. Effective management of drug-induced delirium involves recognition, cessation or dosage reduction of the causative drug(s), and initiation of reorientation strategies and supportive medical care. Specific "antidotes' are appropriate in only a few limited cases. Drug treatment aimed at sedation should be introduced for specific indications, such as aggression, risk of harm to self or others, hallucinations, patient distress, and where compliance with therapy or procedures is essential. Certain benzodiazepines (diazepam, lorazepam, midazolam) and/or haloperidol may be the most appropriate choices in these circumstances. Primary prevention requires the prescription of alternative lower risk medications and the minimisation of polypharmacy. Secondary prevention may be achieved through improved recognition of the condition.

Delirium. Advances in diagnosis, pathophysiology, and treatment

This article discusses research in the areas of morbidity and mortality, epidemiologic risk factors, phenomenology, pathophysiology, and treatment of delirium. Delirium assessment instruments are reviewed. The neuropathophysiologic understanding of delirium is discussed in the context of important CNS neural circuitry. Pharmacologic treatments of delirium in adults and children are outlined, with particular emphasis on intravenous use of butyrophenone neuroleptics.