Tadalafil gehört zur Gruppe der PDE5-Hemmer und wirkt über eine hochselektive Blockade des Enzyms Phosphodiesterase Typ 5. Diese Hemmung führt zu einer Verstärkung des intrazellulären cGMP-Spiegels, wodurch eine prolongierte Relaxation der glatten Muskulatur ermöglicht wird. Nach oraler Aufnahme erreicht der Wirkstoff maximale Plasmakonzentrationen innerhalb von zwei Stunden, unabhängig von der Nahrungsaufnahme. Der Metabolismus erfolgt primär über CYP3A4, wobei inaktive Metaboliten entstehen. Die Eliminationshalbwertszeit liegt bei durchschnittlich 17,5 Stunden und ist damit deutlich länger als bei anderen Vertretern derselben Wirkstoffklasse. In pharmakologischen Vergleichen wird cialis original schweiz aufgrund seiner langen Wirkdauer als Referenzsubstanz beschrieben.

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Differential Diagnosis
Delirium
D – DRUGS!!! (especial y as a medication is introduced or dose adjusted)
L – Lack of drugs (withdrawal: EtOH, opioids, benzos, SSRI/SNRI) • Adapted from: CHAMP: Delirium in Seniors Don Scott MD, University of Chicago R – Restraints, reduced sensory input (vision, hearing) I – Intracranial (CVA, bleed, meningitis, post-ictal) Diagnosis: CAM: 1+2 + (either 3 or 4)
U – Urinary retention or fecal impaction 1= Acute Onset & Fluctuating Course
M – Metabolic including hypoxia (MI, PE), uremia, ammonia, thyroid 2= Inattention
ALWAYS check the MEDICATION LIST – There is a cumulative burden effect.
Any new medication or recent dose change is suspect. Delirium versus Dementia
Common Offenders: (Drug Class and Examples)
Delirium
Dementia
1. Psychiatric medications
a) Antidepressants (tricyclics, SSRI/SNRI) Attention
Consciousness Disordered
d) Other (cholinesterase inhibitors/memantine, lithium) Hallucinations Often Present
2. Anti-histamines /Anticholinergics - (diphenhydramine, hydroxyzine)
Invol. Movmt Often Present
-Many unrelated drugs have anticholinergic activity such as diphenhydramine, tricyclic Risk Assessment at Admission
3. Anti-vertigo/Anti-emetics (metoclopramide, meclizine, promethazine, prochlor
4. Muscle relaxants
5. Anti-spasmodics
a) GI (Donnatal, hyoscyamine, dicyclomine) 1-2 items = Intermediate Risk → OR 2.5 6. Anti-Parkinsons medications
7. Narcotics
8. Corticosteroids
Precipitating Factors During Hospitalization
9. H2 blockers- ranitidine, cimetidine
10. Anticonvulsants
11. Antibiotics – quinolones
Treatment
1. Treat underlying cause/causes
1-2 items = Intermediate Risk → OR 7.1 2. Provide supportive care and prevent complications -Fal s, aspiration, dehydration, pressure sores, iatrogenesis 3. Nonpharmacologic – FIRST LINE THERAPY
Highly vulnerable patient only needs one slight insult, versus low
-Normalize environment - get rid of tethers, keep room calm and quiet,
vulnerability needing a large or numerous small insults.
uninterrupted sleep (no midnight vitals), mobilization/reorientation during day, encourage caregiver involvement/familiar objects -Address/remove risk factors or precipitating agents Does this patient have delirium? JAMA 2010;304(7):779-86. 4. Pharmacologic – only when needed for patient safety Precipitating factors for delirium in hospitalized elderly persons. JAMA 1996;275:852-7. -Agent of choice – Haloperidol (Haldol) (LOW doses to start) 0.5 mg
Delirium in Older Persons. NEJM 2006;354:1157-65. -Atypical antipsychotics (olanzapine, risperidone – start LOW) -Benzos – agent of choice for EtOH withdrawal, otherwise AVOID

Source: http://www.gerisage.com/pocket_cards/Delirium.pdf