WBR1132

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Author [[PageAuthor::Pratik Bahekar, MBBS [1]]]
Exam Type ExamType::USMLE Step 2 CK
Main Category MainCategory::Psychiatry
Sub Category SubCategory::Psychiatry
Prompt [[Prompt::A 80 years old woman is in a nursing home. Her sleep-awake cycle is altered, concentration is impaired, and is not oriented to time place and person. Her symptoms started yesterday and their severity seems to be fluctuating. Her urine examination revealed puss cells and is suggestive of urinary tract infection. There is no history of dementia, stroke, hypertension. What is the first line treatment in the managing delirium?]]
Answer A AnswerA::Haloperidol iv then oral
Answer A Explanation [[AnswerAExp::If non pharmacological techniques fail, or if de-escalation techniques are inappropriate, only then pharmacological treatment is indicated. ECG monitoring is required to calibrate QTc interval. Cardiology consult should be done if QTc interval is more than 450msec or it is greater than 25% baseline. Dose adjustment or discontinuation of antipsychotic medication may be warranted. Haloperidol has can cause sedation and hypotension. Lowering of the seizure threshold, galactorrhea, elevations in liver enzyme levels, inhibition of leukopoiesis, neuroleptic malignant syndrome, and withdrawal movement disorders are rare side effects of antipsychotic medication.]]
Answer B AnswerB::Try to orient her to time, place and person over and over
Answer B Explanation [[AnswerBExp::Non pharmacological methods are the first measure in delirium, unless there is severe agitation that places the person at risk of harming oneself or others.
  • Avoiding unnecessary movement
  • Avoidance of inter‑ and intra‑ward transfers
  • Continuity of care from caring staff
  • Avoidance of physical restraints
  • Involving family members
  • Having recognizable faces at the bedside
  • Sensory aids should be available and working where necessary
  • Maintenance or restoration of normal sleep patterns
  • Approach and handle gently
  • Avoid sudden and irritating noise (e.g. Pump alarms)
  • Careful management of bowel and bladder elimination
  • Having a means of orientation available (such as a clock and a calendar) may be sufficient in stabilizing the situation
  • Reassurance and explanation to the patient and carer of any procedures or treatment, using short simple sentences
  • If this is insufficient, verbal and non-verbal de-escalation techniques may be required to offer reassurances and calm the person experiencing delirium.]]
Answer C AnswerC::Trazadone with first generation antipsychotics
Answer C Explanation [[AnswerCExp::The antidepressant trazodone is occasionally used in the treatment of delirium, but it carries a risk of oversedation, and its use has not been well studied.]]
Answer D AnswerD::Lorazepam with first generation antipsychotics
Answer D Explanation [[AnswerDExp::Benzodiazepines can cause delirium or may worsen the condition. Indication for prescribing sedatives in delirium:
  1. To conduct required diagnostic procedures or to deliver treatment
  2. If patient is danger to others or themselves
  3. Highly agitated or hallucinating patient

Elderly patients and delirium with hypoactive features do not require sedation. All sedatives can cause delirium, especially if drugs like thioridazine, chlorpromazine which have anticholinergic effects. Sedatives must be used with caution with minimum possible dosage and should be discontinued if they are no longer required. Benzodiazepines can be beneficial in a select cases of delirium, such as:

  1. Parkinson's disease
  2. Neuroleptic malignant syndrome
  3. Dementia with Lewy bodies]]
Answer E AnswerE::Morphine and paralysis with mechanical ventilation
Answer E Explanation [[AnswerEExp::Extremely agitated patients, unresponsive to other treatment, may need sedation and ventilatory support. It increases oxygenation and skeletal muscle exertion. Morphine is useful when pain is an important aggravating factor. Opiates, especially meperidine can exacerbate delirium because of their anticholinergic properties.]]
Right Answer RightAnswer::B
Explanation [[Explanation::Delirium is treated conservatively, if non pharmacological techniques fail, or if de-escalation techniques are inappropriate, only then pharmacological treatment is indicated.

Educational Objective: Delirium is treated conservatively, if non pharmacological techniques fail, or if de-escalation techniques are inappropriate, only then pharmacological treatment is indicated.
References: http://www.wikidoc.org/index.php/Delirium_medical_therapy]]

Approved Approved::No
Keyword WBRKeyword::Delirium
Linked Question Linked::
Order in Linked Questions LinkedOrder::
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