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Sundowning & Delirium. Francisco Fernandez, M.D., USF Health, Department of Psychiatry, Tampa, FL Sundowning: Definition. Sundowning  a group of behaviors occurring in some older patients with or without dementia at the time of nightfall or sunset. BEHAVIORS: Confusion

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Sundowning delirium l.jpg

Sundowning & Delirium

Francisco Fernandez, M.D., USF Health, Department of Psychiatry, Tampa, FL

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Sundowning: Definition

  • Sundowning  a group of behaviors occurring in some older patients with or without dementia at the time of nightfall or sunset.


    • Confusion

    • Anxiety, agitation, or aggressiveness

    • Psychomotor agitation (pacing, wandering)

    • Disruptive, resistance to redirection

    • Increased verbal activity

  • Overlap with dementia, delirium, and sleep disturbance.

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Epidemiology of Sundowning Syndrome

  • Not uncommon phenomenon

  • Exact prevalence unknown

  • Reports have ranged between 2.4% and 25%

    • In patients with Alzheimer’s disease or dementia, the range is widened up to 66%

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Risk Factors for Sundowning: Physiologic Factors

  • Circadian abnormalities in elderly and in patients with Alzheimer’s disease progress concomitantly with their behavioral and cognitive dysfunction.

    • Sundowning is more common in AzD.

      • Neurofibrillary tangles found in the hypothalamus of patients with Alzheimer’s may lead to the behavioral changes of sundowning through mechanical disruption of brain tissue.

      • Pathologic damage to the suprachiasmatic nucleus (SCN) is believed to result in disruptive behaviors associated with sundowning.

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Amount of daily light exposure

Activities during the day

Noise level

Disruptions at night


Medical comorbidities

Nursing home residents with sundowning were more likely to

Recent admission

Moved to a new room

Staff shift changes

Low levels of lighting during the day and bright hallway lighting during the night

Increased naptime during daytime hours and reduced nighttime sleep

Risk Factors for Sundowning: Environmental Factors

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Etiology of Sundowning

  • Dysfunction of the circadian rhythm result in disturbed sleep and agitation

    • Deterioration of the SCN seen in patients with Alzheimer’s disease is actively investigated to be an important factor in the disruption of the circadian rhythms.

    • Suprachiasmatic nucleus volume and cell number are found to be decreased in those between the ages of 80 and 100 years.

    • Melatonin is found to be decreased in the cerebrospinal fluid levels of patients with Alzheimer’s disease.

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Mrs. Flabeetz

  • 84 yo female, living at the NH for the last 8 years after a stroke; was having problems managing at home

  • Axis III: Type II Diabetes and hypertension

  • Active in her NH, using her walker; also a little more forgetful and repetitive, and this has been getting slowly worse over the last year

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In the ER…

  • Came into ER after being found on the floor of the NH

  • Unable to get up and complaining of L hip and abdominal pain

  • In the ER, very muddled up & disoriented

  • incontinent of foul smelling urine

  • Picking at imaginary things, scared, and very frightened

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Initial work up…

  • No fracture on X-ray

  • Normal CBC, lytes and troponins

  • CT head shows mild atrophy & bilateral lacunar infarcts

  • Urine collected from foley inserted shows E. coli; started ABX

  • Admitted to Medicine for further assessment and work up of confusion

Alas! It’s been 5 days later, and she’s still not better …


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What would you do?

Is this Delirium? Dementia??

Or something else???

Would you transfer to Psychiatry Service?

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  • Most common psychiatric disorder in the medically ill

  • Point prevalence - 20% of all admissions

    • 30% new onset among medical inpatients

    • 50% medical and surgical patients > 60 yo

    • 89% of patients with known dementia

  • Higher prevalence with increasing age, CNS disease, CABG, and THR

  • NOT a benign condition - sign of impending death in 25% cases

  • Etiology - multifactorial

Rothschild et al, Arch Int Med 2000; Burns et al, JNNP 2004

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Diagnostic Criteria: DSM-IV

  • Disturbance of consciousness (reduced clarity of awareness of environment)

    • Reduced ability to focus, sustain or shift attention

  • A change in cognition (memory, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted by dementia

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Diagnostic Criteria: DSM-IV

  • The disturbance develops over a short period of time (usually hours to days)

  • All abnormalities tend to fluctuate during the course of the day

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Diagnostic Criteria: DSM-IV

  • There is evidence from the medical history, physical examination, or laboratory findings of:

    • A general medical condition etiologically related

      • Sepsis, seizures, tumor, hypercalcemia, hypoglycemia

    • Substance induced intoxication or withdrawal

    • More than one etiology

    • NOS

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“Motoric” Subtypes

Various levels of psychomotor activity

are associated with delirium:

  • Hypoactive

  • Hyperactive

  • Mixed

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Adapted from Ross et al., Int Psychoger 1991

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“Motoric” Subtypes

  • Subtyping not fully accepted by all disciplines

  • Subtyping may have implications for treatment

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Epidemiology & Risk Factors

  • Depending on the cohort, the prevalence of delirium ranges from 8% to 80%

    • Post-surgical rates > general medical patients

    • Advancing age increases the risk (> 60 yoa)

  • 15-20% of patients on a medical surgical ward have an undetected delirious process

Burns et al, JNNP 2004; Kales et al, JNNP 2002; vanZyl & Davidson, Can J Psych 2003

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Epidemiology and Risk Factors

  • The Commonwealth-Harvard Study (Levekoff et al., Int Psychoger, 1991)

    • Patients 65 yoa or older

    • Admissions to Beth Israel Hospital from Hebrew Rehabilitation Center (n=114) and East Boston CHC (n=211)

      • CHC  24.2% were delirious

      • HRC  64.9% were delirious

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Epidemiology and Risk Factors

  • CNS abnormality

    • Dementia, coexisting structural brain disease, and HIV-1 infection increase the risk

  • Drug dependency

    • Alcohol, sedative hypnotics, stimulants, steroid (rapid taper) increase the risk

  • Low serum albumin

    • Malnutrition, chronic disease, aging, nephrotic syndrome, hepatic insufficiency

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Why is Delirium important?

Delirium has a poor prognosis

  • Ý LOS (>7d more)

  • Ý risk dementia dx (55%/2y)

  • Ý ADL decline

  • Ý institutionalization

  • Ý mortality (2.1x/12 mos)

McCusker et al, JAGS 2003; McCusker et al, Arch Int Med 2002;

Rahkonen et al, JNNP; Inouye et al, JGIM 1998

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Delirium Risk : A Predictive model

  • Independent risk factors on admission in a prospective cohort of elderly medical inpts

    1. Vision < 20/70

    2. Severe illness (APACHE > 16)

    3. MMSE <24

Inouye et al, Ann Int Med 1993

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  • Rapid recognition of either prodromal or fully developed clinical features

    • “A,B,C’s” of Neuropsychiatry (Affect, Behavior and Cognition)

      • Prodromal features

        • Restlessness, anxiety, irritability, sleeplessness, hypervigilance, distractibility, fatigue, disinterest, hypersomnolence, inattentiveness, depressed, disillusionment

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Diagnosing Delirium

Delirium Sx Interview

1. Orientation

2. Sleep disturbance

3. Perceptual disturbance

4. Speech disturbance

5. Disturbance of consciousness

6. Psychomotor activity

7. Affect & behavior

Albert et al, J Ger Psych Neurol 1992

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Diagnosis: MSE

  • Mental status examination

    • Cognitive history  chart review

      • What changes (consciousness, restlessness, anxiety, moodiness)

      • When did changes occur (starting/stopping drug, fever, hypotension, deteriorating renal function, rhythm changes)

    • MMSE, focused NBE

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Diagnosis Testing - Standard

  • MMSE & CDT

    • -Not designed for delirium

    • -Useful at separating “normal” from “abnormal”

    • -Not specific for distinguishing delirium from dementia

    • -May be useful as change from baseline

    • -Overkill  add TMT-A, TMT-B

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Diagnostic Testing: Tools

Sensitivity Specificity

  • CAM* .46-.92 .90.92

  • Delirium Rating Scale .82-.94 .82-.94

  • Clock draw+ .87 .93

  • MMSE (24 cutoff) .52-.87 .76-.82

  • Digit span test .34 .90

    *validated for delirium & capable of distinguishing delirium from dementia

    +validated for delirium, correlated with deterioration of dominant frequencies on EEG

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1. [Acute Onset] Is there evidence of an acute change in mental status from the patient's baseline?

2A. [Inattention] Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?

2B. (If present or abnormal) Did this behavior fluctuate during the interview, that is, tend to come and go or increase and decrease in severity?

3. [Disorganized thinking] Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

4. [Altered level of consciousness] Overall, how would you rate this patient's level of consciousness? (Alert [normal]; Vigilant [hyperalert, overly sensitive to environmental stimuli, startled very easily], Lethargic [drowsy, easily aroused]; Stupor [difficult to arouse]; Coma; [unarousable]; Uncertain)

5. [Disorientation] Was the patient disoriented at any time during the interview, such as thinking that he or she was somewhere other than the hospital, using the wrong bed, or misjudging the time of day?

6. [Memory impairment] Did the patient demonstrate any memory problems during the interview, such as inability to remember events in the hospital or difficulty remembering instructions?

7. [Perceptual disturbances] Did the patient have any evidence of perceptual disturbances, for example, hallucinations, illusions or misinterpretations (such as thinking something was moving when it was not)?

8A. [Psychomotor agitation] At any time during the interview did the patient have an unusually increased level of motor activity such as restlessness, picking at bedclothes, tapping fingers or making frequent sudden changes of position?

8B. [Psychomotor retardation]. At any time during the interview did the patient have an unusually decreased level of motor activity such as sluggishness, staring into space, staying in one position for a long time or moving very slowly?

9. [Altered sleep-wake cycle]. Did the patient have evidence of disturbance of the sleep-wake cycle, such as excessive daytime sleepiness with insomnia at night?

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Dx Delirium with CAM

1. Acute onset, fluctuating course


2. Inattention


3. Disorganized thinking


4. Altered level of consciousness

*sensitivity 94 - 100%; specificity 90 - 95%

Inouye et al, Ann Int Med 1990

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Diagnostic Testing: EEG

  • Diffuse slowing

    • Most helpful to get a baseline

      • Patients with AzD may have abnormally slowed EEG

        • Worsens from baseline with delirium

      • Patients with minimal slowing may have test read as “normal”

        • Alpha (13 cps) may slow down (9 cps) and still be in normal range

        • Comparison with baseline

        • Comparison with repeat EEG post delirium

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What Causes Delirium?

The Importance of DDx

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Differential Diagnosis: Urgent

  • When in doubt, throw out the

    • Wernicke’s

    • Withdrawal

    • Hypoxia

    • Hypoglycemia

    • Hyper- hypotension

    • Infection

    • Intracranial bleed

    • Meningitis

    • Poisoning

      • Failure to make these diagnoses may lead to permanent CNS damage

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IInfection:   Most common are pneumonias & UTI in elderly, but sepsis, cellulitis, SBE and meningitis can also occur


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I  Infection 

WWithdrawal:benzodiazapines, ETOH, opiates


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I  Infection 

W  Withdrawal

AAcute metabolic: electrolytes, renal failure, acid-base disorders, abnormal glycemic control, pancreatitis


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I  Infection 

W  Withdrawal

A  Acute metabolic

TTrauma: head injury (SDH, SAH), pain, vertebral or hip fracture, concealed bleed, urinary retention, fecal impaction


I watch death38 l.jpg

I  Infection 

W  Withdrawal

A  Acute metabolic

T Trauma

CCNS pathology: tumor, dementia, encephalitis, meningitis, abscess


I watch death39 l.jpg

I  Infection 

W  Withdrawal

A  Acute metabolic

T Trauma

C  CNS pathology

HHypoxia from COPD exacerbation, CHF


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I  Infection 

W  Withdrawal

A  Acute metabolic

T Trauma

C  CNS pathology

H  Hypoxia 

DDeficiencies: B-12, folate, protein, calories, water


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I  Infection 

W  Withdrawal

A  Acute metabolic

T Trauma

C  CNS pathology

H  Hypoxia 

D  Deficiencies

EEndocrinethyroid, cortisol, cancer


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I  Infection 

W  Withdrawal

A  Acute metabolic

T Trauma

C  CNS pathology

H  Hypoxia 

D  Deficiencies

E  Endocrine

AAcute vascular/MI : stroke, myocardial infarction


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I  Infection 

W  Withdrawal

A  Acute metabolic

T Trauma

C  CNS pathology

H  Hypoxia 

D  Deficiencies

E  Endocrine

A Acute vascular/MI

TToxins-drugs Really anything, but anti-cholinergics, long acting benzodiazepines, narcotics (meperidine) and other psychotropics are common bad actors, OTC, OPM


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I  Infection 

W  Withdrawal

A  Acute metabolic

T Trauma

C  CNS pathology

H  Hypoxia 

D  Deficiencies

E  Endocrine

A Acute vascular/MI

T  Toxins-drugs:

HHeavy metals(lead, mercury, platinum)


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Dementia and Delirium

  • Dementia is a risk factor for delirium

  • Diagnosis of delirium in context of dementia is often missed

    • Of 2000 consecutive admissions:

      • 9.1% of patients had diagnosis of dementia

      • 41.4% of these demented patients had delirious process on admission

        Erkinjuntii et al., Arch Int Med, 1986

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Hallucinations common



Memory disturbance




Hallucinations common only in advanced disease

Delirium versus Dementia?

It is common for Delirium to be superimposed on Dementia!

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So What? Who Cares?Delirium is unimportant!

3 criteria:

Common, Morbidity & Costly!

  • On admit? 15-20%

  • In hospital? 7-31%

  • Ortho - 25-65%

  • ICU: 90%

  • Death ~20-35%

  • Cognitive drop in 40%

  • Premature institutionalization

  • LOS doubles

  • ++ hospital $

  • Caregiver burden

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↓ Physical fn/ immobility

↓ Hearing

↓ Vision

Severity of illness

Comorbid psych dx


EtOH abuse)

Patient Predisposing Factors

Elie et al, JGIM 1998; Burns et al, JNNP 2004

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# of room changes

Absent clock/watch

Absent reading glasses

Absence of family

Bladder catheter



Environmental Predisposing Factors

McCusker et al, JAGS 2001

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Delirium Precipitants

Prospective study incidence of delirium

229 elderly medical inpatients

  • Fluid/ electrolyte dysfunction (40%)

  • Infection (40%)

  • Drugs (30%)

  • Metabolic/Endo (26%)

  • Sensory/ Environmental (24%)

  • ß perfusion/ß O2 (14%)

  • Neurological

  • EtOH/Drug Withdrawal

    **No clear precipitant in 15 – 25%

Francis et al, JAMA 1990

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Delirium Workup


time course of mental status changes

association with other events (i.e.. meds, illness)

Pre-existing impairments of cognition or sensory modalities

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Physical Exam

  • Vitals: normal range of BP, HR, pO2, Temp

  • Good physical exam: particular emphasis on Cardiac, pulmonary and neurological systems

  • Hydration status (dry axilla = dehyd!)

  • Also rule out

    • fecal impaction

    • urinary retention (bladder U/S, in-and-out catheter)

    • Infected decubitis ulcer

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Identify and “correct the correctibles”

Multiple causes in elderly

Careful monitoring

Place patient near nursing station (1:1)

VS, I & O, O2

Reduce psychiatric symptomatology



Discontinue non-essential medication

Drug toxicity and drug induced delirium is most common

See Medical Letter - Drugs that cause psychiatric symptoms

Treatment and Management

  • (Larsen et al., J Gerontol, 1985)

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Treatment and Management


    • Restraints often indicated: posies, vests, mitts, helmets, geri-chairs, locked leathers

    • Provide cognitive structure, emotional support to patient and loved ones

    • Make sure behavioral monitoring is adequate and if empathy exists

    • Soft light, clock, familiar objects from home

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Nonspecific Treatment of Delirium, Mild Agitation, Lability, and Psychosis

A Case for Psychopharmacology

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Clozapine and Psychosis




































Pharmacology Of Atypical Antipsychotics

Zorn SH et al. Interactive Monoaminergic Brain Disorders. 1999:377-393. Schmidt AW et al. Eur J Pharmacol.2001;425:197-201.

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Quetiapine 5HT and Psychosis2 & D2 Occupancy






D2 occupancy

Receptor occupancy (%)


5-HT2 occupancy











Quetiapine (mg/d)

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Injection 2 and Psychosis

(4 hours after 1st injection)

Injection 1

Mean (95% CI) QTc interval

change from baseline (ms)

Mean (95% CI) QTc interval

change from baseline(ms)

IM ziprasidone 20 mg


IM ziprasidone

30 mg*


IM haloperidol

10 mg


IM haloperidol

7.5 mg


IM Ziprasidone vs IM Haloperidol: QTc Interval at Cmax

*IM ziprasidone 30 mg is 50% above recommended dose.

Adapted from Miceli et al. APA poster. 2002.

Preliminary data may not reflect final findings and results from the respective studies.

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Risks of Using v Not Using Atypical Antipsychotics and Psychosis

  • Increased mortality in elderly patients with dementia-related psychosis

    • 17 placebo controlled trials

    • Modal duration of 10 weeks

    • Risk of death in treated patients 1.7 times that seen in placebo treated patients

    • Varied cause

      • CV (HF, sudden death)

      • Infectious

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Final Verdict and Psychosis

  • Atypical antipsychotics are not approved for the treatment of patients with dementia-related psychosis

  • FDA stated “The agency is not advising against all off-label use of atypicals, but is reminding the public that these drugs are not approved fro treating dementia and is advising patients treated with these drugs to have their treatment plans reviewed”.

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If In Its Infinite Wisdom … and Psychosis

  • The FDA were treating a patient, what would they do with

    • Hallucinations

    • Delusions

    • Pressured motor activity

    • Overt aggression

    • Disruptive behaviors

    • Behaviors endangering others

    • Assaults

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What is Best Practice? and Psychosis

  • Assessment

    • Medical risks

    • Psychiatric risks

  • Treatment options

    • Risk v benefits for each

  • Coordinate care with PCP/geriatrician

  • Communicate with PCP and family

  • Establish monitoring system

  • Review literature in support of off-label use

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Start low and go slow and Psychosis

Titrate quickly in patients who are moderately stressed or agitated

Switch agents if patient unable to tolerate

Avoid using if patient recently had a heart attack or stroke unless behavior is life threatening

Reassess need

Every week x 4

Every month x 4

Every 4 months thereafter (if stable)

Reduce dose and monitor

Use lowest effective dose

Eliminate medication if patient is stable

Use prn meds to avoid decompensation

Dosing Atypical Antipsychotics in Dementia

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Nonspecific Treatment of Moderate to Severe Delirium, Agitation, Lability, and Psychosis

A Case for Psychopharmacology

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IV-Haloperidol Agitation, Lability, and Psychosis drug of choice

  • Virtually no anticholinergic or hypotensive properties

  • Generally does not suppress respirations

  • Minimal cardiotoxicity

  • Can be given parenterally without added toxicity

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Treatment of Agitation: Protocol Agitation, Lability, and Psychosis


  • Mild: 1-2 mg haloperidol iv

  • Moderate: 5 mg haloperidol iv

  • Severe: 10 mg haloperidol iv

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MGH Protocol Agitation, Lability, and Psychosis

Keep doubling the dose of iv haloperidol until calm

May require “mega” doses (2 grams/day)

When calm, administer 2/3 total in divided doses

Taper by 10-20% day

MDAH Protocol

Fix IV-H dose at 10mg & add lorazepam

Fix lorazepam dose at 10mg

THI Variant

Add opiate

Buprenorphine (0.1-0.3 mg) to haloperidol-lorazepam

Hydropmorphone (0.5-2 mg) to haloperidol-lorazepam

Treatment of Agitation: Protocol

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Treatment of Severe Agitation: Protocol Agitation, Lability, and Psychosis

  • If previous IV-H protocols fail

    • Trial of continous intravenous infusion of IV-H

      • 10-50 mg/hour

      • 1 - 2 gms/day

    • Trial of droperidol but greater propensity for hypotension limits its use in cardiovascular patients

    • Add opiate

    • Propofol (FDA approved)

    • Paralysis

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Non-pharmacological Interventions Agitation, Lability, and Psychosis

A Case For Risk Factor Reduction

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Interventions To Prevent Delirium Agitation, Lability, and Psychosis

  • 852 patients aged 70+

  • Prospective matching of patients on intervention unit with patients on 2 usual care units

  • Risk factor reduction strategy targetting:

    • cognitive impairment

    • sleep deprivation

    • immobility

    • visual impairment

    • dehydration

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Treatment and Management Agitation, Lability, and Psychosis

  • Unambiguous communication

    • Glasses, hearing aids etc...

    • Avoid medical jargon

    • Communicate succinctly & clearly

    • Make contact while communicating

    • Translators if necessary

Cole et al, CMAJ 2002; Conn & Lieff, Can Fam Phys 2001;

Inouye et al, JAGS 2000

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Treatment and Management Agitation, Lability, and Psychosis

  • Provide cognitive structure, emotional support to patient and loved ones

    • Same staff

    • Quiet; avoid excess noise/stimulation

    • Simplify space

    • Maximize uninterrupted sleep

    • Restraints as last resort for patient safety

    • Make sure behavioral monitoring is adequate and if empathy exists

Cole et al, CMAJ 2002; Conn & Lieff, Can Fam Phys 2001;

Inouye et al, JAGS 2000

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Treatment and Management Agitation, Lability, and Psychosis

  • Maintain function

    • Fluid balance and hydration

    • Adequate nutrition

    • Encourage self-care

    • Walk with assistance or range of motion

      • Minimum – 3 times/day

Cole et al, CMAJ 2002; Conn & Lieff, Can Fam Phys 2001;

Inouye et al, JAGS 2000

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Results Agitation, Lability, and Psychosis

Study Control

Any episode 9.9% 15% p=0.02

# episodes 62 90 p=0.03

Delirium days 105 161 p=0.02

Inouye NEJM 1999

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If it is not delirium, and it is not dementia, and there is no significant agitation …


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To Reduce Sundowning no significant agitation …

  • Provide orientation clues

  • Give adequate daytime stimulation

  • Evaluate for delirium

  • Maintain adequate levels of light in daytime

  • Establish bedtime routine and ritual

  • Provide consistent caregivers

  • Remove environmental factors that might keep patient awake

  • Discourage drinking stimulants or smoking near bedtime

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To Reduce Sundowning no significant agitation …

  • Give diuretics, laxatives early in day

  • Provide personal care at same time each day

  • Ensure patient has glasses, working hearing aid

  • Place familiar objects at bedside

  • Monitor amount of sensory stimulation

  • Consider late afternoon bright light exposure

  • Avoid prn sedative hypnotics

  • Establish regular dose of drug for disturbing behavior (if needed)

  • Assist caregiver in obtaining respite help