12/19 VA report: delirium galore

Thanks to our awesome pall care/geriatrics team for a great talk on delirium, with a focus on the elderly. This was a great reinforcement to last week’s grand rounds on inpatient delirium management!

Delirium is defined by certain key features

  • Acute onset
  • Fluctuating
  • Impaired cognition with disorganized thought
  • Other supporting symptoms: sleep/wake disturbance, emotional lability, perceptual disturbances

Delirium differs from dementia in two key ways: 1) delirium is acute and waxes and wanes and 2) is characterized by inattention.

Here’s a recent JAMA table highlighting key differences:

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JAMA 2017

Common triggers of delirium in the hospital

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So how to manage delirium once you’ve identified it? (…unfortunately it turns out there’s not great evidence for many of the things we commonly reach for)

Non-pharmacologic: redirection, early mobilization, removing restraints/catheters/tele, environmental cues (blinds up during day, dark, quiet room at night)

Pharmacologic: melatonin >> antipsychotics

  • For melatonin, you can start at 3mg and uptitrate. It has few downsides!
    • It has been suggested in multiple studies (including a meta-analysis) to be of benefit in delirium prevention in hospitalized patients
  • If you have to use antipsychotics, start low (ex: 0.5mg haldol), go slow and try to use only in the very short term
    • there is no guideline for switching between antipsychotics, so unclear benefit to doing so

Antipsychotics, on the other hand, are increasingly falling out of favor. Atypical antipsychotics even carry a black box warning because they may increase mortality in the elderly.

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This article suggested that even typical/conventional antipsychotics increased short-term mortality in the elderly: “…patients for whom conventional agents were prescribed had a 37% higher, dose-dependent risk of death in the short term than those for whom atypical agents were prescribed. To place this magnitude of risk in perspective, only cancer, congestive heart failure, and HIV infection conferred greater adjusted risks in our analyses.”

Delirium management summary table

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  1. Oh et al. Delirium in Older Persons: Advances in Diagnosis and Treatment. JAMA 2017.

6/28/17 at HUP: pain management pearls!

We were very excited to welcome new palliative care attending Dr. Jay Vanston to HUP. He gave us an excellent talk on basics of pain management and PCA titration. While I couldn’t possibly capture the scope of the wisdom he imparted in that hour, here are some pearls:


1) If you don’t have IV access, you can give the same dose SQ. Both IV and SQ administration will cause peak effect in ~10-15 min (SQ a little slower)
2) PO doses of most oral opiates peak in ~1h; IV doses peak in 10-15 min
3) Quick tip for fentanyl patch conversion: a 50 mcg fentanyl patch = 50mg PO morphine q12 hours
4) Fentanyl patches have a peak around 12-17 hours after application, so don’t shut off their IV opiates until ~6h after patch placement
5) Methadone potency depends on baseline opiate use. The higher the patient’s baseline opiate use, the more potent methadone will be for that person.

PCA titration

  • Basal dose: start with ~1/6 of the IV dose given over the 1st hour of attempted pain control
  • Bolus dose: generally 1/2 of hourly basal rate, can give q10-15 min
  • Conversion to PO: calculate 24h dose, convert to PO opiate of choice, and divide in half to get long acting (MS Contin/Oxycontin) dosage BID.
  • You can give 10% of the 24h dose as PO breakthrough (generally q2-4h)