Just wondering what you all include as part of your work up for delirium?
What do you include in your delirium work up?
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A note telling the medicine service to do their job.
It depends on the clinical picture, but in general ...
Vitals review, CBC, CMP, UA, UDS, LFT, detailed medication review, NH4+, CXR, CT non-con, +/- MRI, +/- EEG. Once the consult service is called, I have found that medicine has typically not done the med review. They usually don't know the P450 interactions all that well.
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tsh b12
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CBC, CMP, UDS, BDS, UA, CXR, EKG, B12/ Folate, Syphilis IgG, TSH, and med review (opiates, benzos, drug-drug interactions, etc...)
+/- the following: EEG, brain imaging (MRI/ CT without contrast), Ammonia level, HIV
+/- the following: EEG, brain imaging (MRI/ CT without contrast), Ammonia level, HIV
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Also consider an LP (if appropriate), ANA (opening a can of worms).
Basically start with screening labs, dig deeper if you don't come up with anything.
And emphasize to the medicine team that throws the line "well they're not symptomatic" regarding any other organ system that they ARE symptomatic. Delirium indicates a toxicity to the brain, and unlike common teaching is not fully reversible. The longer it goes untreated, the less reversible it is. There is end organ damage taking place, and that organ is the Brain. Failure to fully workup and find an underlying etiology could lead to irreversible brain damage.
I have occasionally documented rationale that strongly to kind of force medicine's hand.
Basically start with screening labs, dig deeper if you don't come up with anything.
And emphasize to the medicine team that throws the line "well they're not symptomatic" regarding any other organ system that they ARE symptomatic. Delirium indicates a toxicity to the brain, and unlike common teaching is not fully reversible. The longer it goes untreated, the less reversible it is. There is end organ damage taking place, and that organ is the Brain. Failure to fully workup and find an underlying etiology could lead to irreversible brain damage.
I have occasionally documented rationale that strongly to kind of force medicine's hand.
it is this sort of attitude for which so many people inside medicine view psychiatry so poorly.....delirium recs are not neurosurgery.
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Nobody should leave a note to a service telling them to do their job, but it's the attitude from medicine that tends to dismiss what psychiatry says that's the problem, not the other way round. And delirium recs aren't neurosurgery... so medicine should know how to do them and follow them. Period.
BTW, you seem to be the night watch of psychiatrists. One mention of bias against psychiatry seems to raise no flags for you, but as soon as one person posts something biased from psychiatry against anyone else you show up to try to keep them in line. I can see why people doubt whom you claim to be, as I do.
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esr (sed rate)
I think there are a couple problems at work here...one is that medicine often consults psychiatry just to 'check a box' and isnt actually that concerned with the input we can offer. Another problem is that sometimes medicine likes to get psychiatry involved in these hopeless delirium cases because there is invariably going to be a messy placement and they are hoping(especially if there is some underlying psych stuff going on as well) that getting us involved earlier gives them a tiny chance of a transfer down the road....
But you are right in that medicine often doesnt read the consult or attempt to follow the consult recs. Thats just because they dont care and dont really believe we have anything to offer.
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Based on your many posts, if you're representing psychiatry to them I can see why they'd get that impression.
From my experience IM docs that consult psych don't feel that way at all. Well let me re-phrase that, many of them dont care about the (specifics of the)psych treatment, but almost all of them believe that psych is providing a valuable resource to the patient and helping them manage the patients issues.
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At the risk of sounding like a broken record: this is likely a sign that your program's psych department is not very strong.
IMHO, hospitals and universities that have a negative view of psychiatry tend to do so because of poor psych leadership, weak psych departments, and below par residents. Strong programs do strong work which leads to a strong reputation of psych. It's not complicated.
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My gripe was more to point out that delirium is a MEDICAL Issue and not a psychiatric issue, contrary to popular opinion. Odd behavior does not immediately constitute a primary psychiatric issue. This type of thinking PLAGUES the emergency room, the doctors therein having missed on more than one occasion active alcohol withdrawal after assuming the patient was just, "crazy".
I am a huge advocate for physicians being physicians, not, "internists, endocrinologists, psychiatrists, etc.". We should all at least make some effort within our level of comfort and ability to think about a patient diagnostically and contribute something to their evaluation prior to consulting another service, even if the thought stops at, "Wow, I really have no idea what is going on and no clue where to start. I need some help".
I am a huge advocate for physicians being physicians, not, "internists, endocrinologists, psychiatrists, etc.". We should all at least make some effort within our level of comfort and ability to think about a patient diagnostically and contribute something to their evaluation prior to consulting another service, even if the thought stops at, "Wow, I really have no idea what is going on and no clue where to start. I need some help".
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One thing I always have to remember is that the psych meds can be exacerbating or continuing the delirium.
60yo man on Inpt Med arrived with sepsis and delirium, no hx of psych or drug/alcohol problems. Sepsis and underlying pneumonia cleared in 3-4 days but the pt continued to have waxing/waning agitation, confusion, not recognizing his wife and (maybe) hallucinations for the next 5 days. He was getting Haldol 5-10mg IV q 4 hrs. The dose per shift varied wildly, typically with 20-40mg on one 12-hr shift because of "agitation" and then none on the next shift because of "over-sedation." On a fixed dose, he got better in 24 hrs and discharged in 36 hrs.
60yo man on Inpt Med arrived with sepsis and delirium, no hx of psych or drug/alcohol problems. Sepsis and underlying pneumonia cleared in 3-4 days but the pt continued to have waxing/waning agitation, confusion, not recognizing his wife and (maybe) hallucinations for the next 5 days. He was getting Haldol 5-10mg IV q 4 hrs. The dose per shift varied wildly, typically with 20-40mg on one 12-hr shift because of "agitation" and then none on the next shift because of "over-sedation." On a fixed dose, he got better in 24 hrs and discharged in 36 hrs.
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Going to a workshop on delirium management at APM on Weds. If anyone else's around it would be cool to say hi. 🙂
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This makes sense to me. Real delirium typically comes from the patient's underlying medical condition (infection, post-surgical, etc), sometimes comes from medications/toxins, and sometimes from new superimposed medical problems like a stroke. I do wonder whether seeing these patients is the best use of a psychiatrist's time since it really does seem to be an IM/toxicology/neurology question first and foremost. Where did the idea that psychiatrists should manage delirium come from?
Disclaimer: I have never been on a psych consult service, but I have managed delirium on IM. We typically just handled it ourselves, and occasionally consulted specialists if we were suspicious for a cause in their area of expertise (for instance, neuro for suspicion of stroke or question of Parkinson's medication dosing in severe AMS).
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The most noticeable symptoms of delirium are behavioral and cognitive. Why wouldn't we be involved?
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Epic bro.
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I think a larger problem is that involvement of psychiatry seems to assuage medicine of its responsibility to find the underlying cause of a delirium. If we prescribe medications for behavioral control, so long as the patient is no longer causing an issue there is little motivation to find the reversible cause. Many times, medicine will gleefully follow the recs to treat the symptomatic component of delirium but invest little interest or time in finding the cause so long as the nurses are happy.
Think of the hypoactive delirium patient. How many nurses will call the medicine attending and say, "Doctor, my patient is very quiet, sleeps a lot, and does not request me to do anything for him. I'm worried something might be wrong."
