Delirium_ Depression_ Anxiety_ and Other Psychiatric Emergencies

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					Delirium, Depression, Anxiety, and Other Psychiatric Emergencies By the end of this class session, you should be able to describe and/or recognize the following concerning Common Psychiatric Issues In the Medical Setting: 1. The diagnostic characteristics of delirium, common causes of delirium, medical evaluation for delirium, and initial treatment for delirium. 2. The features of major depression and identify risk factors for suicide. 3. The difference between competency and capacity and will be able to identify the elements required for evaluation of capacity. 4. The behaviors associated with aggressive behavior in patients and identify a general strategy for management. Dr. Kassaw basically repeated her lecture slides, which are up on BECON, but I put them in writing… Pre-Lecture Questions: 1. Which of the following is a risk factor for completion of suicide? A. B. C. D. Age less than 30 Alcohol intoxication Female gender Married

2. Which of the following is not a protective factor against suicide? A. B. C. D. Children at home Religiosity Polarized thinking Positive social support

3. Which of the following are causes of delirium? A. B. C. D. Metabolic abnormalities Alcohol intoxication Infection All of the above

4. In which of the cases of delirium is Haldol not an appropriate first pharmacologic treatment? A. B. C. D. Infection Alcohol intoxication Metabolic abnormalities Corticosteroids

5. Which of the following is the best treatment for a delirious patient? Correct Answer: Do not over- or under-stimulate the patient.

Psychiatric topics frequently encountered in Medical Setting: Delirium, Suicidality, Agitation and Aggression, Evaluation of Capacity DELIRIUM: - Criteria for diagnosis (summarized from DSM IV)  Disturbance of consciousness with reduced clarity of environment; reduced ability to focus, sustain or shift attention  Change in cognition (e.g. memory deficit) or development of a perceptual disturbance (e.g. hallucinations) that is not better accounted for by a pre-existing or established dementia  Develops over a short period of time (hours to days) and tends to fluctuate over the course of the day (also includes a disturbance of the sleep-wake cycle)  Disturbance is the direct physiologic case of a general medical condition - Presentation can vary from agitated hallucinating patient to calm, non-distressed, quiet individual who is either confused upon inquiry or even mute - Other names:  ICU psychosis (not directly caused by ICU, but very sick patients with disturbed sleepwake cycle causes higher incidence)  “Acute” dementia  Altered mental status  Metabolic encephalopathy - Is a MEDICAL EMERGENCY, associated with increased risk of mortality, prolonged hospitalizations, greater mortality rates for patients months to years out from an episode - Risk Factors  Advanced age (>80)  Azotemia  Severe medical illness  Hypoalbuminemia  Dehydration  Abnormal sodium levels  Fever/hypothermia  Polypharmacy  Substance abuse  Sensory impairment - Most Common Causes  Infections  Medications (esp. anticholinergics, corticosteroids, digoxin, some IV antibiotics)  Withdrawal syndrome (alcohol, sedative hypnotics)  Metabolic Disturbances - WHHHIMP is the mnemonic for the most serious causes that have the highest mortality  Wernicke’s encephalopathy  Hypoxia  Hypoglycemia  Hypertensive encephalopathy  Intracranial hemorrhage  Meningitis, encephalitis  Poisoning  Evaluation: Review history, chart; Physical Exam, Interview Patient if possible  Bedside cognitive tests: MMSE (can follow improvement/decline of symptoms), remembering span of digits, clock drawing (give specific time to draw and pay attention

to where the hands of the clock are placed), trail making tests (patient makes a trail between randomly placed numbers on a piece of paper in ascending order)  Spectrum of tests: BMP, LFTs, CBC, TSH, HIV, B12/folate, RPR, ANA, serum levels of meds, UA, Utox, Blood cultures, ABG, LP, CXR, Head CT, EKG  EEG – most common finding is “diffuse slowing consistent with metabolic encephalopathy” - Treatment:  Identify cause and remove it  If not able to remove (ex. steroids after organ transplant), lower dose  Pharmacology  Haloperidol is relatively safe and good for managing agitation and psychosis associated with delirium  Can be administered PO, IM, or IV (use caution IV as can be associated with toursades if given in a high dose, rapidly infused, or used in a patient with prolonged QTc) Initial Dose of Haloperidol: Severity of Sx Young/Healthy Elderly/Ill Mild 0.5-1 mg 0.5 mg Moderate 2-5 mg 1 mg Severe 5-10 mg 2 mg - Treatment Issues  Avoid using benzodiazepines unless the cause of delirium is alcohol or sedative-hypnotic withdrawal  Benzodiazepines and anticholinergic agents will likely worsen delirium  May also use newer antipsychotic medications such as risperidone (Risperdal), olanzapine (Zyprexa), or quetiapine (Seroquel)  Cholinergic agents such as donepezil (Aricept) have been used  Some controversy about treating the non-agitated delirious patient (side effects of meds may be more harmful – only treat hypoactive delirium if patient is seriously affect, like not sleeping, eating, etc.) - Environmental Treatment  Change lighting to cue day and night  Reduce over- or under-stimulation  Correct visual or auditory sensory impairments  Encourage staff to consistently orient the patient  Encourage familiar individuals to remain with patient  About half of patients remember details of their delirium and find the memories frightening (Watch what you say around a delirious patient)  Use restraint and one on one staff for safety - Support and educate the family  Reassure the family that the symptoms are usually temporary and reversible  Encourage family and friends to reorient the patient and bring familiar items like pictures SUICIDE: - One suicide every 20 minutes in the US

- 9th overall cause of death in the US - Relationship with Gender  Men successfully commit suicide 3 times more often than women (men use more violent methods like firearms, hanging, or jumping from high places)  Women attempt suicide 4 times more often than men (more likely to take an overdose) - Peaks among men after age 45, among women after age 55 - OLDER PEOPLE ATTEMPT SUICIDE LESS OFTEN THAN YOUNGER PEOPLE BUT ARE MORE OFTEN SUCCESSFUL - Psych diagnoses associated with suicide:  Major Depressive Disorder  Anorexia nervosa  Bipolar Disorder  Alcohol and other substance abuse disorders  Schizophrenia  Cluster B personality disorders (particularly Borderline Personality Disorder) - Medical diagnoses associated with suicide:  CNS disease (MS, Huntington’s TBI, spinal cord injury, and seizures)  Cancer  Renal failure on hemodialysis  HIV/AIDS  Pain  COPD - Risk factors  Age 45 or older  Prior inpatient psychiatric treatment  Alcohol Dependence  Recent loss or separation  Irritation, rage, violence  Abuse  Prior suicidal behavior  Loss of physical health  Male  Unemployed or retired  Unwilling to accept help  Single, widowed, or divorced  Longer than usual duration of current episode of depression - Evaluation  ALWAYS ASK - No study has ever shown that asking about suicidal thoughts introduces the idea and precipitates actions.  Are you feeling hopeless?  Do you wish you wouldn’t wake up in the morning?  Do you ever wish you might have an accident resulting in death?  Do you think about harming yourself?  How would you try to hurt yourself?  Do you have the means to do what you are thinking about? (guns, ropes, hoarded medications)  What sort of family or social support do you have?  How would they react if they knew you were thinking of harming yourself or you did harm yourself?  Do you have any spiritual beliefs that discourage suicide?  What do you think would happen to you if you did try to harm yourself?  Do you have any thoughts about how your family or friends would react to your death? (Are they looking for revenge?)  Do you need someone to sit with you to prevent you from harming yourself? - Protective Factors:

 Children in the home (unless postpartum psychosis or mood disorder)  Pregnancy  Religious beliefs  Positive social support - TREATMENT:  Consult a psychiatrist  Document carefully and quote the patient  Suicide prevention contracts have serious limitations and offer no protection (Telling a patient to call you if they think about hurting themselves rarely works)  Seek emergency detention  Confidentiality may be broken if there is fear the patient may be imminently harmful (You can contact a family member or police if you serious think the patient will harm themselves) VIOLENCE IN PATIENTS - Signs of impending violence:  Recent acts of violence, including property violence  Carries a weapon  Progressive physical agitation  Alcohol or other substance intoxication  Paranoid features in a psychotic patient (patients that are just psychotic really are not increasingly violent)  Command violent auditory hallucinations  Brain diseases, particularly those with frontal lobe damage and less commonly temporal lobe damage  Manic patients, particularly when irritable  Agitated depression  Personality disorders with a tendency toward impulsivity (Borderline, Narcissistic, Antisocial) - De-escalating techniques:  Maintain a safe distance  Maintain a neutral posture (do not stare, do not touch the patients, stay at the same height as the patient, avoid sudden movements)  Avoid turning your back on the patient (Dr. Kassaw once got hit in the back)  Speak in a calm, clear voice  Introduce yourself  Avoid confrontation  Acknowledge frustrations and grievances  Try to work toward problem solving and consider possible concessions  Know when to walk away from the confrontation and don’t insist on the last word - Pharm interventions  Benzodiazepines such as lorazepam are usually safe  Antipsychotic medications such as haloperidol or newer agents may be used but acute side effects such as dystonia may increase risk (give anticholinergic medication (benztropine or diphenhydramine) along with to prevent dystonic reactions)


Generally, the combination of an antipsychotic medication and a benzodiazepine is more effective than either agent alone

COMPETENCY AND CAPACITY - Competency is a legal, non-medical term - Competency is determined by a judge, not a physician - Capacity to consent or refuse treatment is determined by a physician (who is not required to be a psychiatrist) *KEY POINT to this section* - Requirements for Capacity  Factual Understanding  Understanding illness, prognosis, risks, benefits  Insight and Appreciation  Understanding that one’s welfare is affected by the decision and the potential to benefit or suffer based on the decision  Reasoning  To be realistic in decision making and use information logically to reach a decision (cannot be delusional reasoning for making a decision, like the blue men told me to)  Evidence a choice or a preference  To be able to express a consistent preference or decision for or against something - Role of Physician  Assess mental status – MMSE, plus assessing appearance, speech, mood, SI, HI  Be alert for psychosis, suicidal ideation, delirium, or dementia  Opinion should be focused on the ability of the patient to make the decision rather than the decision the patient makes!!  Review the medical history of any medications or conditions which might alter orientation or cognition  Explore and relevant personal or cultural beliefs  Ask the patient to articulate how they arrived at their decision  Do not hesitate to contact a psychiatrist or have an ethics and/or legal consult  Carefully document, using quotations to document the patient’s responses - Patient lacking Capacity  Laws differ from state to state regarding what happens in the event a patient lacks decision making capacity  Some examples of surrogate decision making: – Emergency physician consent – Advance directives – Proxy consent – Court appointed guardians – Institutional committees, review panels, or administrators