Geriatric Quick Consult

Delirium

Do # 1

Review ALL medications, and when possible, eliminate any with anticholinergic or CNS-active properties.

Prescribed medications are one of the most common contributing causes in delirium. Cleaning up the med list comes first and foremost! Beers et al.1 developed a widely cited list of medications with potential for causing adverse reactions in older patients. The list is long. Here are some key points.

Knowledge

Action

Medications with anti-cholinergic properties like those to the right often cause delirium.

This relates to neurotransmitter balance in the CNS.

Some medications are more anti-cholinergic than you might think.

Patients often can be safely taken off such meds while inpatients, preventing or lessening delirium.
  • Avoid Benadryl (diphenhydramine)

  • Avoid Atarax (hydroxyzine )

  • Avoid Elavil (amitriptyline)

  • Avoid Zantac (ranitidine)

Sedatives cleared by hepatic oxidative metabolism like those on the right may be cleared slowly in older patients.

The half-life of a drug like Valium (diazepam) may be 2-3 days!

Even short-acting benzodiazepines like Ativan can last for days.

Look back 3 or 4 days in the charted meds for possible culprits.
  • Avoid Valium (diazepam)
  • Avoid Dalmane (flurazepam)

Some medications have surprising CNS activity.

Digoxin can alter CNS function even when levels are "therapeutic."

Delirium is caused by quinolone antibiotic and many other medications.
  • Avoid Digoxin
  • Avoid Ciprofloxacin

Opiate analgesics are a thorny problem.

Treating pain is important, and can reduce delirium.

Yet, opiates can also cause confusion.

Don't use Demerol because it is cleared by the kidneys and can become quickly toxic; other better options exist.
  • Avoid Demerol (meperidine)

References:

  1. Beers et al