Disturbed Patients

INTRODUCTION

Key facts

• Depression affects 15% of people >65 and can mimic or complicate any other illness, incl. delirium (acute brain syndrome) and dementia.

• Elderly patients with depression are at a high risk of suicide.

• Always consider the 4Ds:

  • – dementia

  • – delirium (look for cause)

  • – depression (maybe ‘pseudodementia’ in elderly)

  • – drugs

    • toxicity

    • withdrawal

• Hallucination guidelines:

  • – Auditory: psychoses, e.g. schizophrenia

  • – Visual: almost always organic disorder, illict drugs

  • – Olfactory: temporal lobe epilepsy

  • – Tactile: cocaine abuse, alcohol withdrawal

DEMENTIA (CHRONIC ORGANIC BRAIN SYNDROME)

There is no known cure for dementia—the second commonest cause of death—and tender loving care and behavioural interventions, especially repeated cognitive training and exercises, are important. Assess with the mental state examination (Appendix 2).

Drugs available for Alzheimer disease (modest efficacy)

Cholinesterase inhibitors:

• donepezil 5 mg (o) nocte 4 wks, ↑ 10 mg nocte or

• galantamine PR 8 mg (o)/d 4 wks, ↑ 16 mg d (if tolerated) or

• rivastigmine 1.5 mg (o) bd 2 wks, ↑ 6 mg bd or 4.6 mg transderm ↑ prn

Aspartate (NMDA antagonist):

• memantine 5 mg (o) mane 1 wk, ↑ 5 mg bd wk 2, ↑ 10 mg bd

Psychotropic medication is often not required.

To control psychotic symptoms or disturbed behaviour:

• risperidone 0.25–2 mg (o)/d, ↑ 2 mg/d or quetiapine or olanzapine

To control symptoms of anxiety and agitation:

• oxazepam 7.5 mg (o) 1–4 times/d (short-term use)

Antidepressants for depression—citalopram preferred.

THE ACUTELY DISTURBED PATIENT

Approach to management

• React calmly.

• Try to control the disturbed patient gently.

• Ensure the safety of all staff.

• An adequate number of staff to accompany the doctor is essential—six is ideal (one for immobilisation of each limb, one for the head and one to assist with drugs).

• Benzodiazepines usually the drug of first choice for tranquillisation. Oral preferred if possible but parenteral most practical.

Treatment options (if appropriate)

Oral: diazepam 5–20 mg (o), rpt 2–6 hrly or lorazepam 1–2 mg (o), rpt 2–6 hrly; add olanzapine 5–10 mg or risperidone 0.5–1 mg if nec.

Parenteral: diazepam or midazolam 2.5–5 mg increments IV, repeated every 3–4 mins until required level of sedation reached (max. 20–30 mg) or if IM route best

• – droperidol (Droleptan) 5–10 mg IM (probably best) or

• – olanzapine 5–10 mg (o) up to 30 mg/d (watch for possible laryngeal dystonia and treat with benztropine 2 mg IM) or

• – midazolam (Hypnovel) 2.5–10 mg IM as single dose

• – then search for the cause and/or refer accordingly

DELIRIUM (ACUTE ORGANIC BRAIN SYNDROME)

Diagnostic ...