Stopping all psych meds in delirium?

[nexus73]

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I was curious what your practice is (or what you were taught in residency if no longer doing inpatient/CL work) regarding psych meds and delirium. Do you automatically stop all psychoactive meds (antidepressants, mood stabilizers, antipsychotics, etc) in delirious patients, or take each medication individually considering deliriogenic potential?

 

[Celexa]

If you do anything automatically in CL, you're gonna get yourself (and your patient) in hot water.

I do neither. I evaluate each medication in the clincial context of the patient and their acute medical situation .

Stopping all psychotropics by reflex is terrible practice. Treating each medication as though their deliriogenic potential is an intrinsic property of the medication and not something that depends on numerous other clincial factors is only marginally better.

 

[thelastpsych]

You should evaluate individually, and pay attention especially to the cholinergic load of the patients meds, not only their psychotropics - a ton of meds can alter a patient cholinergic burden and change their mental status dramatically. There are even calculators online for a patients cholinergic burden: https://www.acbcalc.com/

Pay close attention to benzos as well!

 

[annoyedpsychiatrist]

i agree. case by case basis. Something like benzos though i may make reductions on at least. I look individually at the medications, diagnosis of patient, and likely contributors to delirium

 

[Merovinge]

You should evaluate individually, and pay attention especially to the cholinergic load of the patients meds, not only their psychotropics - a ton of meds can alter a patient cholinergic burden and change their mental status dramatically. There are even calculators online for a patients cholinergic burden (acbcalc.com is an example).

Pay close attention to benzos as well!

Can you link the correct site, I am very interested in that but it appears to go a defunct webpage.

 

[MacDonaldTriad]

Most delirious patients are geriatric. Geriatric patients tend to have multiple physician providers and they don't communicate well. It is standard operating procedure on inpatient geri psych to stop most everything and watch the patient improve. The exceptions are Benzos, and maybe anticonvulsants depending on the indications. Then you let them get better and reintroduce judiciously depending on what you are treating.

 

[comp1]

No, I don't automatically stop anything. If you're just randomly pulling meds, you're as likely to worsen the delirium as improve it. Concur with looking at the anticholinergic burden. I very rarely see patients coming in with delirium already on high dose benzos, fortunately. They'd certainly need to be tapered in that case, if not held, due to the dose.

 

[thelastpsych]

Can you link the correct site, I am very interested in that but it appears to go a defunct webpage.

That's odd, I copy and pasted the correct URL, but it still redirects to another site.
I'll try it in this comment: ACB Calculator

 

[mistafab]

For my approach, I typically will try to keep stable things stable if I can get away with it. If they are on very deliriogenic medications that are easy to peel off such as cyclobenzaprine, atarax, or nightly sleep meds I typically will peel those off. I try not to mess with their stable baseline meds otherwise if they are not significantly contributory to delirium.

Benzos are more case by case depending on the situation. There's significant temptation there to peel them off, but withdrawal will be very deliriogenic so the juice is not worth the squeeze in many cases.

Reducing polypharmacy overall is a definite guiding principal.

 

[Celexa]

Most delirious patients are geriatric. Geriatric patients tend to have multiple physician providers and they don't communicate well. It is standard operating procedure on inpatient geri psych to stop most everything and watch the patient improve. The exceptions are Benzos, and maybe anticonvulsants depending on the indications. Then you let them get better and reintroduce judiciously depending on what you are treating.

Geriatric psych inpatient and CL have overlap but are not at all the same patient population. Every geri unit I've worked in or sent patients to will reject a clearly delirious pt, as they should, since the right place for them is usually the medical floor. By definition patients on a geriatric psych floor have decompensated psychiatric symptoms of some type.

Most delirious patients go from the medical floor to non-psych settings, often back to their current outpatient prescribers, and don't have any decompensated psych symptoms in the first place. You often can't tell what their baseline is when they are delirious, and collateral may or may not be available and (since they're delirious) there is some type of active medical issue. If you start discontinuing meds bc the regimen looks bad you will tend to introduce even more variables unnecessarily into a situation undergoing active workup. The major exception is going to be if you suspect med non compliance and the team ordered the patients alleged home meds and now you see the pt demonstrating likely signs of suddenly being given a bunch of stuff they weren't actually taking. But again, that's gonna be a case by case decision based on history and exam.

I don't disagree with your statements in terms of what often needs to happen on a geri psych unit and the frequent benefits of decreasing polypharm, but as a general modus operandi that's just not representative of how to manage delirious pts on a CL service. Most of the delirious pts we see have never and will never have an indication to be admitted to inpatient psychiatry.

 

[Stagg737]

You should evaluate individually, and pay attention especially to the cholinergic load of the patients meds, not only their psychotropics - a ton of meds can alter a patient cholinergic burden and change their mental status dramatically. There are even calculators online for a patients cholinergic burden: https://www.acbcalc.com/
Pay close attention to benzos as well!

Can you link the correct site, I am very interested in that but it appears to go a defunct webpage.

I would urge a bit of caution when using that site/calculator. The calculator is not based on EBM and the points for medications were determined by “expert opinion”, some of them without real evidence for their rating. Our Geri department loves it and when I’ve pushed back on some of their reflex calculations they had no answer to legitimate concerns. For example, lexapro used to give the same number of points as paroxetine and amitriptyline for anticholinergic burden.

 

[ClosetCentrist]

I would urge a bit of caution when using that site/calculator. The calculator is not based on EBM and the points for medications were determined by “expert opinion”, some of them without real evidence for their rating. Our Geri department loves it and when I’ve pushed back on some of their reflex calculations they had no answer to legitimate concerns. For example, lexapro used to give the same number of points as paroxetine and amitriptyline for anticholinergic burden.

Additionally, the whole idea of antimuscarinic burden being clearly associated with delirium is on much shakier ground than you might think. The original paper that associated serum antimuscarinic activity with delirium has failed to replicate a few times now. Benzos and opioids are the only two things that I have seen consistently replicate as deleriogenic in the literature.

Plus, you know, the fact that quetiapine doesn't actually seem to make things any worse (though probably also not any better) flies in the face of the antimuscarinic hypothesis.

I wrote an essay on this specific topic, though I can't say I came out the other side feeling any more confident about what were supposed to do from a psychopharmacologic point of view: Wot's Uh... The Deal With Antimuscarinics and Antihistaminergics in Delirium?

 

[Merovinge]

Additionally, the whole idea of antimuscarinic burden being clearly associated with delirium is on much shakier ground than you might think. The original paper that associated serum antimuscarinic activity with delirium has failed to replicate a few times now. Benzos and opioids are the only two things that I have seen consistently replicate as deleriogenic in the literature.

Plus, you know, the fact that quetiapine doesn't actually seem to make things any worse (though probably also not any better) flies in the face of the antimuscarinic hypothesis.

I wrote an essay on this specific topic, though I can't say I came out the other side feeling any more confident about what were supposed to do from a psychopharmacologic point of view: Wot's Uh... The Deal With Antimuscarinics and Antihistaminergics in Delirium?

I'm open to further insight into this area but can't say that tracks with my understanding. I have several patients that intentionally take 10x dosages of Benadryl (500ish mg) and absolutely hallucinate/have symptoms that are consistent with delirium. I believe the "mushroom" chocolates/pills that is supposedly psilocybin that is being sold all over social media is reportedly just an anticholinergic toxin that apparently makes people feel weird enough they believe is psilocybin.

 

[MacDonaldTriad]

Poly pharm is probably the most frequent causes of geri delirium. My advice to stop everything is a generalization as I already said, but it is also rational in a large number of cases. Even if an acute medical cause for the altered mental status is known, simplifying the regiment makes sense. Too many cooks get patients into trouble and digging patients out of trouble can require a hard reset. You may say my advice is too cookie cutter, but even if that is true, look at the admission orders of delirious geri cases and see what doctors do no matter what they say they believe their core values are telling them.

 

[Candidate2017]

Stopping all psychotropics is a classic move from the IM primary team and other medical consultants. They suddenly forget they are physicians and turn into the lay public who like to play the game of "blame it on the psych meds". Also, reviewing anticholinergic burdens or benzos is easy enough for the primary team to do. Even med students know how to do it as part of a standard medical workup.

 

[ClosetCentrist]

I'm open to further insight into this area but can't say that tracks with my understanding. I have several patients that intentionally take 10x dosages of Benadryl (500ish mg) and absolutely hallucinate/have symptoms that are consistent with delirium. I believe the "mushroom" chocolates/pills that is supposedly psilocybin that is being sold all over social media is reportedly just an anticholinergic toxin that apparently makes people feel weird enough they believe is psilocybin.

Diphenhydramine is where my mind first went when I started thinking about this too, but it doesn't seem quite so simple to me. Diphenhydramine is not just an antimuscarinic, it's strongest affinity is actually for H1 so how does that fit in? Though at 500mg you're probably close to saturation of M1-M5 too. Maybe there's some weird functional selectivity going on? I dunno.

Quetiapine/norquetiapine suggests that there's much more to this story - it has very similar affinities to diphenhydramine at the histamine and muscarinic receptors but we can dose above 800mg and we're not usually making people delirious. Similarly it's not clear to me why olanzapine doesn't make things worse in delirium.

 

[Merovinge]

Diphenhydramine is where my mind first went when I started thinking about this too, but it doesn't seem quite so simple to me. Diphenhydramine is not just an antimuscarinic, it's strongest affinity is actually for H1 so how does that fit in? Though at 500mg you're probably close to saturation of M1-M5 too. Maybe there's some weird functional selectivity going on? I dunno.

Quetiapine/norquetiapine suggests that there's much more to this story - it has very similar affinities to diphenhydramine at the histamine and muscarinic receptors but we can dose above 800mg and we're not usually making people delirious. Similarly it's not clear to me why olanzapine doesn't make things worse in delirium.

It can't just be H1 blockade though. We had people take trazodone at 600mg back in the day and I don't think seeing shadow figures coming through the vents was a typical response.

Seroquel is a bit different in that while you do have the marked H and M receptor impact, you also had dopamine blockade. It's also just a profoundly confusing drug in general given the active metabolite, long half life and very dirty binding profile. I am not sure that would be my reference for why H and M blockade does not lead to delirium.