CL psych and brain failure

[Cath Up]

I am a resident that has done a little over 3 months of CL. I really try to read on medical topics as they come up so as not to lose all my medical knowledge, but it’s hard. I am definitely no diagnostic genius, unfortunately.

I am fascinated by delirium, especially the absolutely wacky incompatible realities that patients can report while delirious (e.g., one pt telling me we are hiding from a wind storm in an office building downtown, and that we are in a hospital). But also, I have become extremely frustrated by it. There are sometimes plausible etiologies like uti, uremia, hepatic encephalopathy, surgery. But often- nothing specific. Just a patient with a ton of comorbidities and frailty, no egregious opioid/bzd/histamine/anticholinergic/cns depressant burden. I sometimes go looking for zebras and have never found one. For these patients, CL psych is consulted, and I can recommend a laundry list of solid measures to help, but it feel generic. I am not solving the mystery, and I have no certainty about what is actually causing the brain to fail- no idea when or how to be certain when there are reliably 5 reasonably explanative subacute issues happening all at once for a patient.

Is this what CL psychiatry is like? Are people out there actually figuring out the most likely precipitants?

I am comfortable with the agitation side of things- that all makes sense and psychiatry can be helpful getting the right meds on board. But am also curious about anyone’s use of dopamine antagonists for active treatment. I am aware of limited evidence for this- at best something like low dose haldol might help a little, but there’s evidence going both ways. But I also know the morbidity/mortality of delirium is absolutely atrocious and the dogma I have been exposed to most is that these outcomes warrant as aggressive a treatment as possible, despite dopamine antagonists not really addressing the underlying cause. I’d be curious to hear perspectives on this take.

---

Members don't see this ad.

 

[Crayola227]

I'm not sure what the question is. It doesn't seem much more mysterious than when you have a patient get cytokine storm and ARDS, or the coagulopathy you can see in obstetric patients hemorrhaging, or coagulopathy in cancer, or paraneoplastic conditions.

We are an absolutely delicicately balanced bag of millions of enzymes and chemicals. When you take a salad kit, empty out the components and toss the salad, it isn't any wonder.

What is more remarkable, is how preserved brain function often is, even with remarkable organ failure and derangements. The ability to maintain homeostasis in that system to where you can basically be actively dying, organs failing, waste products accumulating, yet pretty much cognitively intact, really speaks to just how hardy the system really is.

Given just how bad or idiosyncratic it must be for such a system to fail as spectacularly as we see it in severe delirium, it shouldn't be that surprising that, at that point all we really have is generic to address it. We can't pin anything down, because there is nothing to pin down. The salad has to, sort itself out?

There are a lot of causes of pulmonary failure or kidney failure, yet at the end of the day the basic intervention when the organ is just failed, is pretty simple.

Delirium isn't that different. It happens and the best you can do is supportive care, address what medical and other variables can be addressed and hope for the best.

A lot of medicine is just, supporting the body's natural processes. Which sounds so much like that naturopathic drivel that I just said that I want to kick myself in the mouth, but yeah.

Had an interesting lecture from a critical care guy, who said, you don't "save" your patients. You intubate, you do whatever supportive stuff, and then they either heal, their body gets better, or they don't. Other specialties might be more, directed, but we're talking illness on a level that surgery or what have you is not touching.

Another example. Antibiotics don't "cure" infection by killing all the bacteria. Almost all of them work to literally just slow growth to the point the immune system can catch up and finish the job. It seems like the antibiotic is doing it, but it might kill 20%, but the other 80% is the immune system. This is why even in the absence of an issue with drug resistance, most patients get better but not all.

So in delirium, we don't fix the brain. What is wrong is more global. It might seem like it was as simple a trigger as UTI, but likely more was going on. You already identified that it seems like there are usually multiple issues. Lots of young patients get UTI and usually they would have to be septic before you would see delirium. Older patients, rarely is the only issue UTI, and now they have delirium. It was just the thing that tipped that already delicate balance.

But it's always easier to upset the apple cart, then to get the cart back on the wagon back on the horse and with all the apples back inside.

 

[hebel]

Time is one of the most effective treatments in all of medicine. I shared similar feelings to you while doing CL and often felt that many of our consults would have fixed themselves if the team simply waited 48-72 hours before calling us (in cases of delirium).

However, sometimes there primary team could absolutely make some changes to make things better and every now and then you do actually catch some zebras!

 

[nexus73]

sometimes you catch some obvious things the primary team missed, most often catching medication issues, like patients continued on home dosing of multiple BEERS meds they can tolerate when stable but fall apart with an acute medical issue on top of the meds, or sometimes you see several acute/subacute/chronic issues and allows you to explain to the primary team why it's delirium because of anemia, chronic hypoxia, mild AKI, plus the pneumonia they were admitted for. Usually in the latter case the primary team is saying the pneumonia isn't severe enough so they don't expect the level of delirium they're seeing, but with the other factors it starts to make sense.

Or a cards patient getting 30 mg Ambien over night due the standard PRN order allowing a repeat 10 mg, then the night doc got called and gave verbal order for a 3rd 10 mg, and next day patient is completely out of their mind. You can't "fix" that problem outside of time and managing agitation, but you get to explain to cards that it's not new schizophrenia in an 82 year old man.

Or the patient admitted with SBO that spontaneously resolved, but then started losing her mind on hospital day 2. History of bipolar so it must be mania. But when consulted, the CL psychiatrist finds out she drinks. A lot. It's like an 18 pack of beer daily and family doesn't remember the last time she didn't drink 18 beers a day, and she's 70 years old. So it's alcohol withdrawal delirium not mania. Which makes a lot more sense because she's seeing cats on the drapes of the hospital room, and there are definitely no cats in her room, and the window doesn't even have drapes.

I'm pretty sure the delirium research states cause of delirium is almost always multifactorial or the underlying cause is often not found, so you do your best to look for factors to fix, but you may not be able to identify anything and it's just time.

 

[comp1]

It looks like your main question is about what CL psychiatry is like? It's not mostly about delirium and doing impressive detective work, I can tell you that. From my experience, it was mostly about providing supportive psychotherapy to stressed out medical teams and trying to help them set boundaries on severe Cluster B personality pathology exacerbated by medical stress. I always conceptualized the person in the bed as only the identified patient, but the real group you're providing care to is the medical team and my goodness are there often a lot of them. And yeah, as above, time is how most things in medicine are treated. Your job in CL will be getting the medical team to tolerate that as opposed to the non-stop search for a magic pill that makes the patient polite and agreeable.

 

[Cath Up]

I'm not sure what the question is. It doesn't seem much more mysterious than when you have a patient get cytokine storm and ARDS, or the coagulopathy you can see in obstetric patients hemorrhaging, or coagulopathy in cancer, or paraneoplastic conditions.

We are an absolutely delicicately balanced bag of millions of enzymes and chemicals. When you take a salad kit, empty out the components and toss the salad, it isn't any wonder.

What is more remarkable, is how preserved brain function often is, even with remarkable organ failure and derangements. The ability to maintain homeostasis in that system to where you can basically be actively dying, organs failing, waste products accumulating, yet pretty much cognitively intact, really speaks to just how hardy the system really is.

Given just how bad or idiosyncratic it must be for such a system to fail as spectacularly as we see it in severe delirium, it shouldn't be that surprising that, at that point all we really have is generic to address it. We can't pin anything down, because there is nothing to pin down. The salad has to, sort itself out?

There are a lot of causes of pulmonary failure or kidney failure, yet at the end of the day the basic intervention when the organ is just failed, is pretty simple.

Delirium isn't that different. It happens and the best you can do is supportive care, address what medical and other variables can be addressed and hope for the best.

A lot of medicine is just, supporting the body's natural processes. Which sounds so much like that naturopathic drivel that I just said that I want to kick myself in the mouth, but yeah.

Had an interesting lecture from a critical care guy, who said, you don't "save" your patients. You intubate, you do whatever supportive stuff, and then they either heal, their body gets better, or they don't. Other specialties might be more, directed, but we're talking illness on a level that surgery or what have you is not touching.

Another example. Antibiotics don't "cure" infection by killing all the bacteria. Almost all of them work to literally just slow growth to the point the immune system can catch up and finish the job. It seems like the antibiotic is doing it, but it might kill 20%, but the other 80% is the immune system. This is why even in the absence of an issue with drug resistance, most patients get better but not all.

So in delirium, we don't fix the brain. What is wrong is more global. It might seem like it was as simple a trigger as UTI, but likely more was going on. You already identified that it seems like there are usually multiple issues. Lots of young patients get UTI and usually they would have to be septic before you would see delirium. Older patients, rarely is the only issue UTI, and now they have delirium. It was just the thing that tipped that already delicate balance.

But it's always easier to upset the apple cart, then to get the cart back on the wagon back on the horse and with all the apples back inside.

Thank you for your thoughts- I appreciate the perspective.

 

[Cath Up]

sometimes you catch some obvious things the primary team missed, most often catching medication issues, like patients continued on home dosing of multiple BEERS meds they can tolerate when stable but fall apart with an acute medical issue on top of the meds, or sometimes you see several acute/subacute/chronic issues and allows you to explain to the primary team why it's delirium because of anemia, chronic hypoxia, mild AKI, plus the pneumonia they were admitted for. Usually in the latter case the primary team is saying the pneumonia isn't severe enough so they don't expect the level of delirium they're seeing, but with the other factors it starts to make sense.

Or a cards patient getting 30 mg Ambien over night due the standard PRN order allowing a repeat 10 mg, then the night doc got called and gave verbal order for a 3rd 10 mg, and next day patient is completely out of their mind. You can't "fix" that problem outside of time and managing agitation, but you get to explain to cards that it's not new schizophrenia in an 82 year old man.

Or the patient admitted with SBO that spontaneously resolved, but then started losing her mind on hospital day 2. History of bipolar so it must be mania. But when consulted, the CL psychiatrist finds out she drinks. A lot. It's like an 18 pack of beer daily and family doesn't remember the last time she didn't drink 18 beers a day, and she's 70 years old. So it's alcohol withdrawal delirium not mania. Which makes a lot more sense because she's seeing cats on the drapes of the hospital room, and there are definitely no cats in her room, and the window doesn't even have drapes.

I'm pretty sure the delirium research states cause of delirium is almost always multifactorial or the underlying cause is often not found, so you do your best to look for factors to fix, but you may not be able to identify anything and it's just time.

Probably part of the dread of delirium consults is knowing it just bought me a ton of chart review and note writing to communicate possible causes. But this reinforces that such a review is essentially why we are brought on board. It's just frustrating when the answer is 5 separate processes that need time, and there's no clear cause, because I have no concrete explanation (but as others mention, certainly a coherent plan to help and reassurance/explanation for the primary team). Thanks.

 

[Cath Up]

It looks like your main question is about what CL psychiatry is like? It's not mostly about delirium and doing impressive detective work, I can tell you that. From my experience, it was mostly about providing supportive psychotherapy to stressed out medical teams and trying to help them set boundaries on severe Cluster B personality pathology exacerbated by medical stress. I always conceptualized the person in the bed as only the identified patient, but the real group you're providing care to is the medical team and my goodness are there often a lot of them. And yeah, as above, time is how most things in medicine are treated. Your job in CL will be getting the medical team to tolerate that as opposed to the non-stop search for a magic pill that makes the patient polite and agreeable.

I want to make sure that my rather insular experience is similar to the experience of others- in certain ways it is not. We treat delirium with low dose antipsychotics routinely in the absence of agitation, which I do not believe is heavily supported by evidence. Most especially, I am seeking reassurance that I am not totally incompetent for often not being able to identify previously unidentified causes of delirium in complex medical patients. What I'm hearing is that this can sometimes be done, but there's a lot more to it in terms of how psych can help.

I appreciate the concept that CL psychiatry is heavy on the liaising- it's often a doctor's doctor type of role which is cool.

 

[ObsequiousAplomb]

I want to make sure that my rather insular experience is similar to the experience of others- in certain ways it is not. We treat delirium with low dose antipsychotics routinely in the absence of agitation, which I do not believe is heavily supported by evidence. Most especially, I am seeking reassurance that I am not totally incompetent for often not being able to identify previously unidentified causes of delirium in complex medical patients. What I'm hearing is that this can sometimes be done, but there's a lot more to it in terms of how psych can help.

I appreciate the concept that CL psychiatry is heavy on the liaising- it's often a doctor's doctor type of role which is cool.

The low-dose antipsychotic thing is rather fascinating. There's so much evidence that says it's really not the best practice, yet everywhere I have ever worked it's what the psychiatrist end up recommending. They all come up with their own rationalizations for why, and most are aware that they are being irrational. It is what it is.

 

[comp1]

The CL psychiatrists aren't being irrational with SGAs. They are doing harm reduction. Medical teams, including nurses, need a pill to be given when a patient is becoming agitated. This is inborn (some sort of fear response?) and, as far as I can tell, completely impossible to eradicate, regardless of amount of education provided by a consultant about behavioral interventions. It's a core belief. So...if you don't recommend something else, the patient is going to get a benzo. Meds are always going to have to be recommended, but in a more functional setting there will also be practices that are evidence based to supplement meds that might be less so. The only way to overcome this barrier is to actually develop an effective medication for agitation in delirium (or dementia for that matter).

 

[ObsequiousAplomb]

The CL psychiatrists aren't being irrational with SGAs. They are doing harm reduction. Medical teams, including nurses, need a pill to be given when a patient is becoming agitated. This is inborn (some sort of fear response?) and, as far as I can tell, completely impossible to eradicate, regardless of amount of education provided by a consultant about behavioral interventions. It's a core belief. So...if you don't recommend something else, the patient is going to get a benzo. Meds are always going to have to be recommended, but in a more functional setting there will also be practices that are evidence based to supplement meds that might be less so. The only way to overcome this barrier is to actually develop an effective medication for agitation in delirium (or dementia for that matter).

Where I am they would not need to be told not to use benzodiazepines. In fact, aside from alcohol withdrawal, I've never seen someone try to give benzodiazepines to medical inpatients tbh. Usually they need to be promoted to do that even. They're usually giving the patient haloperidol already.

And you definitely proved my point by providing a rationalization. You said that because you can't educate them correctly, you educate them to use low dose antipsychotics (that is to say, to avoid them not getting your message, you change your message to the message you know isn't factually correct).

The placebo you're telling them to give could be anything. It might as well be trazodone 12.5 mg if it is going to be quetiapine 12.5 mg, etc. Why choose the class that has been shown to hasten death in that population over literally any other thing?

You're also proposing to treat the patient with a medication when the person with the disorder that you say you're treating with the antipsychotic isn't the patient. Explain it all you want, that's not exactly rational (and I know what you mean, and frankly, I agree with you).

 

[mistafab]

The low-dose antipsychotic thing is rather fascinating. There's so much evidence that says it's really not the best practice, yet everywhere I have ever worked it's what the psychiatrist end up recommending. They all come up with their own rationalizations for why, and most are aware that they are being irrational. It is what it is.

This is a debate/conversation I was having just today.

Low-dose antipsychotics (i.e. haldol 0.5-1mg) in non-agitated delirium don't have great data to say it improves medium or long term outcomes. however, there is decent data to say it helps short term outcomes (aka "clinical improvement") on delirium scales, which equates to being 'less confused'.

I like to say this is akin to tylenol for a fever. It does not make the course of the illness shorter. However, it does make the suffering decrease from the subjective experience of the patient.

So although I don't routinely start low dose APs in non-agitated delirium, that is at least my rational using what data is available. It is just impossible to design a good study in this given how many causes of delirium there are - and the fact that even if you improve the delirium, they are still very medically sick so the 'outcome' may not change. We can at least say that data show that EPS rates in these patients from AP use is very low (8% or less), and that there is no clear evidence of the low dose AP making them worse.

 

[comp1]

Tylenol for a fever is a good metaphor as long as you conceptualize it as treating the medical team's anxiety about the fever.

 

[ObsequiousAplomb]

Tylenol for a fever is a good metaphor as long as you conceptualize it as treating the medical team's anxiety about the fever.

I like that, only I don't think Tylenol has a black box warning for use in elderly patients, the ones we're most often seeing with delirium.

 

[Crayola227]

Practically speaking, even with a sitter, redirection, reorientation using day/night cues, minimizing disruption, and fall precautions like a bed alarm (and lowering the bed which I've seen in theory but never an option on the med floor), besides a fear response in the nurse or sitter from the agitation, this issue is the very real thing, that it is extremely difficult to treat patients that keep getting out of bed and ripping out IVs. This is fact. You can use physical restraints but depending on the patient this can actually make things worse. So the reality is that something sedating ends up being used as a kind of chemical restraint.

The problem is we know all those drugs are themselves deliriogenic. So again, it becomes a balancing act. Can you use just enough drug to calm the patient just enough, to give treatment for medical problems like UTI, decompensated heart failure, etc, so that those are not ongoing factors, and then hope they start to get better, and you need less chemical restraint and can start to wean what may now be the main offender, the drug itself.

As for the choice of drug, my sense is that a whiff of antipsychotic is better than benzo, but that's not really based on anything.

The whole thing about the black box warning, is to say, whatever you get from antipsychotics in this setting, well, it's not for nothing. Be aware.

But in medicine, on one hand, I have the very real and possibly hourly danger of the patient falling out of bed, hitting their head, and the for sure harm of them ripping out a necessary central line delivering drugs they need 100%, vs the theoretical harm of the antipsychotic meant to keep everyone safe and pliable.

We can't embrace for sure major harms to prevent possible ones.

I once had a teaching scenario with med students. The patient is an unconscious pregnant woman with concern for bleeding out somewhere. U/s not really helpful. So a student orders a hypothetical CT. The other student says, "But they're pregnant!" Well, the life of the mother comes first. You can't embrace the very real harm that she is bleeding out and you don't know where or what to do about it, to avoid the risk the CT harms the pregnancy. You always have to deal with the real problem in front of you, with an eye for how what you choose in the moment might cause downstream problems, and kind of worry about some of the risks down the road.

Same thing when you consent patients for blood products and talk about the one in a million of HIV which always seems to freak patients out (understandably). Um, but your risk of MI is like 50% if we don't get your crit up 🤔

The black box warning is more useful when it comes to more longterm management of these patients in the community. Still a risk assessment.

Lastly, multiple reasons that the primary team likes to bring psych on board. Yes, acute management of delirium really shouldn't be beyond the average generalist doc. Understandably if you have a more complex situation like your bipolar patient on lithium and a list of other compounds, some psych meds, some sedating, then it makes more sense to consult psych.

My sense is that, there are multiple other reasons that essentially psych is brought in to make the sign of the cross over the patient and bless the current course in the notes, most of which are probably more medicolegal and reassuring to patient families than anything else.

I mean, assuming you have someone who can recognize delirium 🤣 I don't know what went wrong in so many people's medical education.

It's like when you have an otherwise stable patient in who happens to have cancer but no active therapy, current problems have nothing to do with cancer. Unsolvable problem, may not have much impact on anything going on while they are in the hospital. You consult onc even though you guess there will be no real input or change. It just seems right to bring in certain specialists to have them essentially just say, well there's nothing else to be done. This is a bad example in some ways, my point is that intractable problems with no clear solutions tend to beget consults.

I agree there is an anxiety element that causes a lot of meds to be prescribed and consults to be called. But as I've argued, what else can you do? 🤣

But yes, the impact delirium has on treating the patient, compared to other problems we have no magic wand for, makes the primary team and nurses feel especially helpless. Because we all are.

I was getting paged to bedside so many times for a mildly agitated delirious patient we couldn't medicate any more than we were, a real big guy, that I just posted up on a computer outside their room. Had a nurse come up and thank me just for my presence 🤣 somehow that was reassuring to the nurse and sitter. Maybe because they thought they could drop this big guy a lot faster if the doc was right there for the order. Maybe the diffusion of responsibility. Of course the downside is you get hauled in constantly to try to reason with the patient. But you know then you share in the impossibility of the situation and understand why you get paged every time these patients do something.

If the patient wasn't delirious, the team could handle belligerent and refusing treatment. If they were cops they could use force on someone for whom force seems the only answer because reasoning can't be done. Nothing in the general arsenal works.

Sometimes I wonder if half the problem is we have strangers being the ones providing care. In delirium as opposed to dementia, family seems to be a much more welcome influence to the patient. Not always but often.

 

[comp1]

Just to keep things concrete...the black box warning is for dementia. I'm not saying haldol in delirium is totally safe, all good. I'm just saying there isn't a specific black box warning regarding it. And heck now, for dementia related agitation, we have an actual FDA approved med that somehow walks a tight rope of psychosis versus agitation.

 

[Crayola227]

Just to keep things concrete...the black box warning is for dementia. I'm not saying haldol in delirium is totally safe, all good. I'm just saying there isn't a specific black box warning regarding it. And heck now, for dementia related agitation, we have an actual FDA approved med that somehow walks a tight rope of psychosis versus agitation.

Excellent point! Just goes to show often silly docs get the D words mixed mentally sometimes

Just goes to show just how useful I think the black box warning is. I take it as, just prescribe this unless you really have to for safety.

 

[mistafab]

Yeah this has become an internal debate for myself at this point.

As silly as it is, the best corrolary I have is a tylenol in fever analogy, The data does not point towards harm from use, nor towards long or mid term benefit. Yet, there are definitely subjective reports from patients describing delirium as especially traumatic and suffering-inducing. For which, subjectively, the symptoms improve in short term with APs per the data (i.e.CAM scores), and long term AP use side effects/risks are not significant factors given short duration of use at low doses.

A good debate for psychiatrists to have. The data is too weak to be sure here — at least we don’t see clear harm. A tool in the toolbelt that can be used as needed, such as delirium w/ frequent getting out of bed favoring a trial.

I think the real debate is how low can we go in terms of effective dosing of d2 agents. The effect is often seen at lower doses than we imagine, and we describe it being due to a dopamine/ach ratio rather than general dopamine tone… yet where is the data? Maybe it is just placebo and treating provider teams / nursing staff. Another red herring is that quetiapine/olanzapine seem to work just as well as haldol. Why would they? Shouldnt they make things worse? Yet the data says otherwise.

 

[aim-agm]

The problem is we know all those drugs are themselves deliriogenic.

Except for alpha-2 agonists. Non-deliriogenic and very effective, but also very underutilized.

 

[TheRightMedication]

Regarding the OP's feeling that these consults are "generic" - they are. Helping to manage polypharmacy can provide a bit of intellectual stimulation, and is a great service to the patient and the team.

I don't know why otherwise skilled, competent doctors don't seem interested in anticholinergic burdens and QT prolongation. Maybe they want to leave us something to do so we feel productive. So you have that to look forward to.

Diagnostically you probably won't be finding glorious zebras left and right. It's more likely you'll contribute by identifying catatonia, drug induced Parkinsonism or even NMS (perhaps of your own doing), and less likely serotonin syndrome.

I did C and L part time for years and 3/4 time for one year before I got bored of it. This was at a community hospital.

 

[ObsequiousAplomb]

I understand the use of antipsychotics in agitation, in any delirium where the patient has physically harmed themselves that hospitalization (e.g. removing lines, resisting staff attempting to care for them, etc). I get that for people who have been severely delirious with prior infections of that type, when they come back for another one, prevention with a standing low dose antipsychotics may even be reasonable (if not clearly effective in the literature).

My main "ick" with the recs I read are when they say all three of these three things for a patient that hasn't been violently agitated (and more than half the consult notes I have read do say all three of these):
1. Avoid all sedating medications.
2. Avoid all anticholinergic medications
3. Seroquel or Zyprexa are the only antipsychotics mentioned.

From what I can tell, NPs, PAs, and psychiatrists all are guilty of this. MDs and DOs are less likely to have a blatantly contradictory recommendation like that, but at a lot of these systems it's in the template because an MD wrote it and didn't think to clarify that they believe for whatever reason that the anticholinergic and sedating properties of Seroquel 12.5 mg are good for some reason but Benadryl 25 mg are bad.

 

[nexus73]

I understand the use of antipsychotics in agitation, in any delirium where the patient has physically harmed themselves that hospitalization (e.g. removing lines, resisting staff attempting to care for them, etc). I get that for people who have been severely delirious with prior infections of that type, when they come back for another one, prevention with a standing low dose antipsychotics may even be reasonable (if not clearly effective in the literature).

My main "ick" with the recs I read are when they say all three of these three things for a patient that hasn't been violently agitated (and more than half the consult notes I have read do say all three of these):
1. Avoid all sedating medications.
2. Avoid all anticholinergic medications
3. Seroquel or Zyprexa are the only antipsychotics mentioned.

From what I can tell, NPs, PAs, and psychiatrists all are guilty of this. MDs and DOs are less likely to have a blatantly contradictory recommendation like that, but at a lot of these systems it's in the template because an MD wrote it and didn't think to clarify that they believe for whatever reason that the anticholinergic and sedating properties of Seroquel 12.5 mg are good for some reason but Benadryl 25 mg are bad.

Seroquel anticholinergic effects don’t start until higher doses, I’ve heard

 

[Crayola227]

Seroquel anticholinergic effects don’t start until higher doses, I’ve heard

For naive patients even whiffs (well, I've never seen 12.5 as a dose, more like 25-50 mg) I've seen cause some sedation. Some ppl also seem especially sensitive to that.

Same with urinary retention and swallowing symptoms, although usually it's more an issue for a patient who has other factors that cause those things.

 

[ObsequiousAplomb]

Seroquel anticholinergic effects don’t start until higher doses, I’ve heard

Do you have a source? I would love to be wrong if it meant that low dose Seroquel isn't anticholinergic. I'm fairly certain that all you get at the lower doses are antihistamine and anticholinergic effects.

Again, it's not unreasonable in young people with delirium. The overwhelming majority of the delirium I have seen is in the setting of dementia, that is why I mentioned the black box warning above. The quetiapine is continued at discharge and then just gets continued for 6+ months. That's what I was griping about up thread. I agree with what everyone has said here.

 

[Crayola227]

Do you have a source? I would love to be wrong if it meant that low dose Seroquel isn't anticholinergic. I'm fairly certain that all you get at the lower doses are antihistamine and anticholinergic effects.

Again, it's not unreasonable in young people with delirium. The overwhelming majority of the delirium I have seen is in the setting of dementia, that is why I mentioned the black box warning above. The quetiapine is continued at discharge and then just gets continued for 6+ months. That's what I was griping about up thread. I agree with what everyone has said here.

I don't have a source, but I have heard from someone who tends to be pretty evidence based, that there is evidence even at lower doses before you see significant effect on dopamine receptors, that quetiapine has a positive effect on sleep architecture.

This may explain why a low dose seems to work well as a sleep aid for some folks, and yet as a better sleep aid then another drug that causes sedation and is just primarily an anticholinergic.

The theory I've heard is that, at low doses despite lack of activity at some receptors, and activity at others (anticholinergic), there are still other receptors being activated. As we know many of these drugs may have "main activity" but in reality many of them are quite sloppy.

I know I'm not providing a source but this kind of "doctor gossip" is occasionally useful if someone did go looking.

It could also just be "psychological," that people feel better giving a "psych" drug in delirium than just milking the side effect of a drug with a totally different and seemingly unrelated, indication. Even though you might argue low dose antipsychotic is not "treating" the "mind" and you are also still just capitalizing on a side effect.

But if it did have a positive effect on sleep architecture at low doses, then you're not just exploiting a side effect at that point, and then it would theoretically a better choice than say benadryl.

 

[Celexa]

One thing I haven't seen addressed yet is that hypoactive delirium can cause fairly profound subjective distress, and this is a valid reason for giving low dose antipsychotics.

My rule is I recommend meds for agitation which interferes with care, subjective distress, and sleep-wake regulation. Usually patients need at least one of those and the psychodynamic needs of the primary team are met. Frequently we end up recommending discontinuing or taking out something else they started. Commonly I see patients taken off their home benzo for no good reason and started on new meds which can be jsut as bad (ugh, baclofen) and so I gently nudge the teams back to the big picture.

I think there's a common learning cycle which goes something like this:

1. I know nothing so everything is interesting.
2. I know something and ugh, so many of these cases are the same, this is boring
3. I have expertise, and have the insight to see most cases are unique in their own way, and can find something I can help with that is satisfying

I went through this with delirium cases and am firmly at stage 3.

I enjoy the bizarre and interesting cases we get on CL very much, and sometimes I do get to play detective, but it's working with the patients and the teams and my trainees that makes it sustainable. The case can be very routine to me, but if the team is grateful for my help, that's worth it in and of itself.

 

[aim-agm]

To briefly divert the thread...whereas:
1. Delirium is a latin for "out of [his] furrow"
2. Some smells, such as lavender, can be calming and useful in delirium
3. Delirium can occur at any age, including neonates

Your assessment and recommendations for a NICU consult could be:
"Not groovy baby, needs flower power!"

 

[clausewitz2]

To briefly divert the thread...whereas:
1. Delirium is a latin for "out of [his] furrow"
2. Some smells, such as lavender, can be calming and useful in delirium
3. Delirium can occur at any age, including neonates

Your assessment and recommendations for a NICU consult could be:
"Not groovy baby, needs flower power!"

I hate you and simultaneously want to award you a medal of some kind, a very curious ambivalence.

 

[nexus73]

To briefly divert the thread...whereas:
1. Delirium is a latin for "out of [his] furrow"
2. Some smells, such as lavender, can be calming and useful in delirium
3. Delirium can occur at any age, including neonates

Your assessment and recommendations for a NICU consult could be:
"Not groovy baby, needs flower power!"

More helpful than majority of tele psych consults I’ve seen