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Dr. Andrew Rynne

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Suggest treatment for delirium

Answered by
Dr.
Dr. Prakash H Muddegowda

Geriatrics Specialist

Practicing since :2004

Answered : 2138 Questions

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Posted on Tue, 26 Aug 2014 in Elderly Problems
Question: Med Background: elderly male with COPD, pleural effusion, CCF (with pacemaker), hypoxia, type 2 diabetes, 2 TIAs in recent year, recent fall & small fracture (non ambulant), myeloproloferative disorder.
1) If someone with the above med problems has a sudden onset of delirium (which includes agitation, worsening dysarthria & confusion) then within what time frame should it be reported to a doctor? Why? Are there any serious possibilities that may need urgent medical attention?
doctor
Answered by Dr. Prakash H Muddegowda 1 hour later
Brief Answer:
Delirium should be reported immediately.

Detailed Answer:
Hi,
Thanks for asking.
I am Dr. Prakash HM and I will be answering your query.

For query
1. Time frame - should be immediately or as early as possible.

2. Delirium usually occurs when there is an external insult powerful enough to disrupt its normal functioning is present.
Delirium in the elderly is known to be associated with increased short term mortality mainly due to underlying physical illness.
Repeated episodes of delirium or prolonged delirium has a poor prognosis.

Things which require attention include:
1. Pneumonia
2. Adverse drug reactions
3. Cerebral hypoxia
4. Acid-base imbalance
5. Septicemia
6. Diabetic ketoacidosis
7. Dehydration

Above are some of the possibilities, and risk of each is definitely high with multiple risk factors (medical background).

Delirium is not a condition to be ignored and requires immediate hospitalization for evaluation of underlying factors and to treat the cause.

Hope it helps.
Any further queries, happy to help again.

Dr. Prakash HM
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Prakash H Muddegowda 24 hours later
Dear Dr. Muddegowda,the same elderly person now has suspected sepsis and probable pneumonia (although he remains afebrile), and he appears to be in pain. He has been administered 0.5 mg haloperidol IMI for agitated delirium but it has had no effect whatsoever after 2 hours. I understand that haloperidol usually manages to sedate elderly people who have delirium. (1) Could the fact that the haloperidol has been inefficacious indicate that something is seriously amiss? If so, what serious possibilities are there? (2) Generally speaking, given the age of the patient and his comorbidities, how quickly should the nil effect of the haloperidol be reported to a doctor. Why? The patient is still on O2 and a high dose of frusemide, although no analgesia at this stage.
doctor
Answered by Dr. Prakash H Muddegowda 4 hours later
Brief Answer:
Increase in dose might be necessary.

Detailed Answer:
Hi,
Thanks for asking.

In delirium with agitation, the initial drug of choice is halperidol.

It should begin to work within 30 minutes or even earlier as was given in intramuscular format.

The dose might be low as the elderly person is not responding, and dose can be increased. During dose increase watch out possibilities for extrapyradimal neurological symptoms like dystonia, dyskinesia or muscle stiffness..

Discuss with your doctor regarding change of dosage.

Any further queries, happy to help again.

Dr. Prakash HM
Above answer was peer-reviewed by : Dr. Bhagyalaxmi Nalaparaju
doctor
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Follow up: Dr. Prakash H Muddegowda 16 hours later
Thank you Dr XXXXXXX HM. Additional information for recent days: (RR 19, SPO2 81% 99% & 95% while on oxygen, BP 104/60 & 112/69, HR 92), next day (RR 19, SPO2 100% 81% 98% & 85%, BP 102/62 106/70, HR 96 53 100-108 irregular 78) BP has been low like this for weeks and still afebrile. As you cannot personally examine the patient and have limited information, I appreciate that it is difficult for you to give a definitive medical opinion. But the patient is now in pain. Would you have any serious concern that the administration of analgesia could mask the patient's ability to recover (perhaps by affecting vital signs)? Nothing can be guaranteed, but could there be a reasonably safe way of administering analgesia and how could one go about it. The delirium is worse and the patient is now nil by mouth. We know that he is extremely sick and realise his age is not helping.
doctor
Answered by Dr. Prakash H Muddegowda 7 hours later
Brief Answer:
Administration will definitely mask signs.

Detailed Answer:
Hi,

Thanks for asking again.

Looking at the medical reports and query, my opinion is as follows:
1. Oxygen saturation appears to be good and improving
2. Being afebrile is good. It indicates no serious inflammation or infection.
3. Respiratory rate is near normal limits. Lung function is maintained well.
4. Blood pressure, if it falls below 90/50, I will be worried. At present, it is maintained well.
5. At present there is no reason to have pain of any specific location. Yes, if analgesia is given beforehand, it might mask any temperature variation or any pain at any location. As any main cause is yet to be specifically evaluated, precautionary treatment could complicate things.
6. As he is in delirious state, anything by mouth could be aspirated into lungs, so should be avoided.
7. Yes Age does not help, that does not mean, he wont come out of it. Once, the right cause is identified, he could recover back to his prehospital days.

Hope it helps.
Any further queries, happy to help again.
Dr. Prakash HM
Above answer was peer-reviewed by : Dr. Ashwin Bhandari
doctor
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Follow up: Dr. Prakash H Muddegowda 40 hours later
Thank you Dr XXXXXXX HM for your previous medical opinions. I am grateful for your expertise. The patient is now on 3 antibiotics for probable pneumonia and suspected sepsis (although two blood cultures were negative). It is still the case that no one can locate the site of the pain, although it is agreed that he is in pain. Would you have any major reservations about commencing the administration of analgesia now that IV antibiotics are being used? BP, HR & RR are much the same at present and the patient remains afebrile despite the diagnoses. Would you be greatly concerned that analgesia might lower BP too much? Could there be an administration of some analgesia that would minimise the risk of affecting BP, HR, RR, etc. The patient does have poor renal function but his liver is OK. Again, I appreciate that you are not in a position to personally examine the patient and don't have total information. I recognise that it is not always possible for you to give definitive answers to my questions.
doctor
Answered by Dr. Prakash H Muddegowda 21 minutes later
Brief Answer:
Antibiotics should work

Detailed Answer:
Hi,
Thanks for asking again.
Based on clinical history and query, my opinion is as follows:

1. Unless a cause is identified and the pain is debilitating, I would not start analgesia. As it is still probable and not final, any analgesia, even paracetamol would mask the symptoms.

2. He is still afebrile, so any NSAID analgesics, have additional antipyretic effect and would mask fever. The poor renal function also wont support additional analgesia, otherwise, renal failure might complicate things.

3. Even if the liver is functioning well, he is already on three antibiotics and that is also high. I would not want to load the liver more with drugs to metabolize. The analgesia could trigger liver damage. Analgesics are commonly known to do that.

4. Good emotional support would be helpful.

5. I would wait for a specific sign or symptom in the present context. The antibiotics should work and improvement should be seen within two days.

Any further queries, happy to help again.
Dr. Prakash HM
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Prakash H Muddegowda 21 hours later
Thank you for your much valued medical opinions. I thought that I would fill you in on the latest developments. The patient continues to deteriorate. His BP, HR & RR are much the same, but his delirium is worse. He has been on 3 antibiotics for about a day now, but you did say that it may take a couple of days before there is any sign of improvement. I can provide you with more information about his medical background. Several weeks ago he had suspected pneumonia which seemed to clear, but his C Reactive Protein & WCC remained high, eg, a week ago his CRP was 126.9 mg/L and his WCC was 14.4. Yesterday's results: CRP was 147.3 mg/L, WCC was 17.8, creatinine was 173, albumin was 35 g/L, venous lactate was 4.1, actual bicarbonate was 32 mmol/L, estimated GFR has been declining over the last few days & was 34 yesterday, pO2 was critical at 46 mmHg. I don't know what it means for a pO2 to be critical. Today's results: CRP is 189.2 mg/L, WCC is 13.4, creatinine is 174, albumin is 28 g/L, INR 2.1, but no lactate or pO2 done today. I can now fill you in on recent and present pathology results. I thought that it might be worthwhile to get an updated opinion from you. However, I realise that you cannot physically examine the patient and that you have only been provided with limited medical data.
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Follow up: Dr. Prakash H Muddegowda 4 hours later
More information: sodium was high yesterday at 146 mmol/L but has gone up today to 150mmol/L. What action should now be considered? The dose of frusemide (Lasix) was increased to 120 mg twice daily weeks ago.
doctor
Answered by Dr. Prakash H Muddegowda 2 hours later
Brief Answer:
CRP needs to come down

Detailed Answer:
Hi,
Thanks for asking again.
After going through the clinical details and lab reports, I can give my opinion as follows:
1. CRP is very high indicating severe inflammation. Cause is probably sever pneumonia.
2. X-ray findings or CT findings should confirm the diagnosis of severe pneumonia
3. pO2 level has reduced, and is critical as the oxygen saturation has come down. He must be probably on ventilator support. His respiratory rate should have increased in response to reduced oxygen saturation, but is not as his respiratory muscles might be tiring.
4. His sodium level is high and if it increases further can lead to further delirium due to hypernatremia itself. More fluids cannot be loaded as his renal function is deteriorating. If it progresses, he would need dialysis.
5. Overall position at present is appearing grim. CRP needs to come down, which would indicate reducing inflammation, along with the oxygen saturation or pO2 needs to improve. Hope he improves soon. Family support and reassurance is most important now.

Hope it helps.
Any further queries, happy to help again.
Dr. Prakash HM
Above answer was peer-reviewed by : Dr. Bhagyalaxmi Nalaparaju
doctor
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Follow up: Dr. Prakash H Muddegowda 17 hours later
Thank you greatly Dr Prakesh HM for the continuing benefit of your expertise. It is now 2 days since the commencement of antibiotics. However, there has been a continuing deterioration and his agitated delirium is obviously worse. Blood test results early this morning: sodium up to 157 mmol/L, potassium is 3.4 mmol/L, urea is 34.0 mmol/L, creatinine is 204, estimated GFR is 28, WCC is 13.9, HB is 119 g/L, PCV is 0.390 L/L, MCV is 103.0 fL, RCC is 3.80, MCHC is 305 g/L, RDW is 22.3%, neutrophils are 10.7, INR is 2.2, C Reactive Protein is 162.0 mg/L. Last night BP systolic was still above 100, but BP has now dropped to 85/60. Is there anything at all that can be done now if he doesn't go on to dialysis? You said yesterday that the overall position appeared to be grim. Did you mean that it was unlikely that he would survive if he didn't get dialysis? Since his blood pressure has dropped so much could taking him off frusemide (Lasix) 150 mg twice daily do anything to help if he doesn't get dialysis?
doctor
Answered by Dr. Prakash H Muddegowda 3 hours later
Brief Answer:
Low blood pressure, possibly cardiac dysfunction

Detailed Answer:
Hi,
Thanks for asking.
Based on your query, my opinion is as follows:
1. Drop in blood pressure is not due to frusemide alone, it is more due to cardiac dysfunction. The heart is unable to manage the load and its ability to function optimally is reducing.
2. Dialysis is required at these levels of sodium, as present sodium levels are already adding to increased delirium. However, the low blood pressure, would be difficult to manage during dialysis procedure and there could be serious complications now, if dialysis is tried.
3. None of the values are showing any improvement, and fall in blood pressure and rise in sodium is worsening the prognosis.
4. Overall situation is difficult.

Any further queries, ready to help again.
Dr. Prakash HM
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Prakash H Muddegowda 21 minutes later
Thank you Dr XXXXXXX HM. A decision has been made that he is not suitable for dialysis which seems to be what you think, too. Even though low BP is not due to frusemide alone would you judge that, on balance, it is best to cease frusemide? Is there any risk in doing so? I appreciate that it is a complex situation and it is difficult to be certain. You are also not in a position to personally examine the patient. However, would you say that it seems, on the basis of the limited data that I've provided, that the prognosis is very poor, especially given that there will be no dialysis?
doctor
Answered by Dr. Prakash H Muddegowda 52 minutes later
Brief Answer:
Stopping Frusemide will worsen condition.

Detailed Answer:
Hi,
Thanks for asking again.
Based on your queries, i can give my opinion as follows:
1. Frusemide is the drug, which is controlling most of the important values, by improving renal function. If it is ceased, it will accelerate the deterioration of all functions and overall situation will worsen.
2. Yes, Stay close him. The scope for any improvement is very low.
Take care.
Any further queries, ready to help again.
Dr. Prakash HM

Above answer was peer-reviewed by : Dr. Yogesh D
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