U of T Delirium protocol draft
Intro/disclaimer: this is a brief summary of up-to-date available peer reviewed lit. compiled by
members of the PH&D Program . It is meant as a general guideline, and should not surplant your
clinical judgement-every case needs to be assessed on its merits.
procedure
1 Screening
action
Confusion Assessment Method
reference
1.
2.
2 Diagnosis
3
Investigation
4
see
attached
algorithm
“figure 2”
Management
5
Treatment
considerations
6
Prognosis
Do MMSE, MOCA, Clock,
AND
observe for features of CAM
1. review medical history
2. consider drug
intoxication/withdrawl
(*note exception below)
3. metabolic evaluation
4. consult int med.
1. general orienting procedures
2. intervention aimed at
underlying problem-note
CIWA for etoh*
3. Reccomended options?:
Haldol +Ativan?
4. Quitiapine
Does This Patient Have Delirium?: Value
of Bedside Instruments Camilla L. Wong;
Jayna Holroyd-Leduc; David L. Simel; et
al.JAMA. 2010;304(7):779-786
Inouye SK, van Dyck CH, Alessi CA,
Balkin S, Siegal AP, Horwitz RI. Clarifying
confusion. Ann Intern Med.
1990;113(12):941-948.
1. X
2.
3.
Postoperative Delirium
Gregory L. Fricchione, M.D. Shamim H.
Nejad, M.D. Justin A. Esses, M.D.Thomas J.
Cummings, Jr., M.D. John Querques, M.D. Ned H.
Cassem, M.D.George B. Murray, M.D. Am J
Psychiatry 165:7, July 2008
4.
1.
2.
3.
X
x
X
Delirium in Older Persons
Sharon K. Inouye, M.D., M.P.H. N Engl
J Med 2006;354:1157-65.
4. Efficacy and safety of quetiapine in
critically ill patients with
delirium: A prospective, multicenter, randomized,
double-blind,
placebo-controlled pilot study*
John W. Devlin, PharmD; Russel J. Roberts,
PharmD; Jeffrey J. Fong, PharmD; Yoanna
Skrobik, MD; Crit Care Med 2010 Vol. 38, No. 2
1. Qtc interval with neuroleptic
use-guidelines
2. OTHERS???
1.
Richard R. Riker, MD; Nicholas S. Hill,
MD; Tracey Robbins, RN; Erik
Garpestad, MD Antipsychotic drugs:
Prolonged QTc interval, torsade de
pointes, and sudden …Alexander H
Glassman; J Thomas Bigger Jr The
American Journal of Psychiatry; Nov
2001; 158, 11; Research Library pg. 1774
1.
2.
3.
4.
1.
2.
3.
X
X
Symptoms of Depression and Anxiety
After DeliriumDimitry
S.Davydow,M.D.Psychosomatics 2009;
50:309 –316
4.
X
overall outcome
reduction in level of function
depression/anxiety
PTSD
7 Prevention
1.
Inouye SK, Bogardus STJ Jr, Charpentier
PA, et al.A multicomponent intervention
to prevent delirium in hospitalized older
patients. N Engl J Med. 1999; 340(9):669676.
2. Cochrane Database Syst Rev. 2007 Apr
18;(2):Interventions for preventing delirium in
hospitalised patients.Siddiqi N, Stockdale R,
Britton AM, Holmes J.
Principles: start low , go slow etc
Notable exceptions: * ETOH withdrawl-use CIWA (under addictions section of on call
resource)
Investigations algorithm, from:
Postoperative Delirium Gregory L. Fricchione, M.D. Shamim H. Nejad, M.D. Justin A. Esses, M.D.Thomas J.
Cummings, Jr., M.D. John Querques, M.D. Ned H. Cassem, M.D.George B. Murray, M.D. Am J Psychiatry 165:7,
July 2008