Differential Diagnosis
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)
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
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


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