Psychiatry - October 2008 - (Page 31)

delirium, antipsychotics are the drugs of choice and should be administered at the lowest adequate dosages. For more threatening agitation, a combination of antipsychotics and benzodiazepines along with ventilatory support has been utilized.8 Haloperidol, a typical antipsychotic, is the most frequently used and best studied antipsychotic medication for delirium due to its few anticholinergic side effects, few active metabolites, and small likelihood of causing sedation. Most studies have used doses of haloperidol from 0.25 to 0.50mg every four hours for the elderly or seriously medically compromised patients to doses of 2 to 3mg per day in healthier patients. For very agitated patients, bolus doses of 5 to 10mg per hour intravenously have been used in hospital settings.9,10 The main outcome measures for these studies were the Brief Psychiatric Rating Scale, Schedule for Affective Disorders Scale, Clinical Dementia Rating Scale, and the Behavioral Syndromes Scale for Dementia. A study with haloperidol, chlorpromazine, and lorazepam groups have demonstrated improvements in the mental status as measured by the Delirium Rating Scale in the haloperidol and chlorpromazine groups but not the lorazepam groups.11 A criticism of this study is that the mean doses of haloperidol and chlorpromazine were low 1.4mg per day and 36mg per day respectively, while the dose of FIGURE 1. Cholinergic (red), dopaminergic (yellow), and serotonergic (blue) projection systems in the brain. TABLE 2. The differential diagnosis for delirium using the mnemonic “I WATCH DEATH” INFECTION Encephalitis, meningitis, syphilis, HIV, sepsis WITHDRAWAL ACUTE METABOLIC TRAUMA CNS PATHOLOGY HYPOXIA Alcohol, barbiturates, sedative-hypnotics Acidosis, alkalosis, electrolyte disturbance, hepatic failure, renal failure Closed-head injury, heat stroke, postoperative, severe burns Abscess, hemorrhage, hydrocephalus, subdural hematoma, seizures, stroke, infection, tumors, metastases, vasculitis Anemia, carbon monoxide poisoning, hypotension, pulmonary or cardiac, cardiac failure DEFICIENCIES Vitamin B12, folate, niacin, thiamin ENDOCRINOPATHIES Hyper/hypoadrenocorticism, hyper/hypoglycemia, myxedema, hyperparathyroidism ACUTE VASCULAR TOXINS OR DRUGS HEAVY METALS Hypertensive encephalopathy, stroke, arrhythmia, shock Medications, illicit drugs, pesticides, solvents Lead, manganese, mercury KEY: CNS—central nervous system; HIV—human immunodeficiency virus Adapted with permission from The American Psychiatric Press Textbook of Consultation-Liaison Psychiatry. Washington, DC: American Psychiatric Press, Inc., 1996. [OCTOBER] Psychiatry 2008 31

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Psychiatry - October 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Treatment of Migraine and the Role of Psychiatric Medications Play Therapy: A Case-based Example of a Nondirective Approach Delirium and Antipsychotics: A Systematic Review of Epidemiologyand Somatic Treatment Options Severely Mood-disordered Youth Respond Less Well to Treatment in a Community Clinic than Youth with Bipolar Disorder Beyond Informed Consent: The Ethics of Informing, Anticipating, and Warning Asthma: Wheezing, Woes, and Worries Classified Advertising Journal Watch Information for Authors

Psychiatry - October 2008

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