Ms. Griffiths was the doyen of her local Methodist Church.  Always a smile, a compliment, asking after family, a basket with freshly baked bread.  Today I hardly recognized her. Her hair was dirty and uncombed, the bed was unmade and she was crying out when the nurse tried to help her; she was terrified.  This was delirium, again.  We were having a run with this being the third case this week.

That evening several on our team were meeting for a beer at a new microbrewery near the hospital.  As is often the case, despite our best efforts, talk of work came up.  What can we do about delirium? Recent studies indicate that treating delirium with medications is not helpful. Many of those medications, like haloperidol, have black box warnings and would be on the Beers list, and are not recommended to be given to elders in nursing homes.

A quick look on the phone….

Delirium

  • anticholinergics
  • antipsychotics
  • benzodiazepines
  • chlorpromazine
  • corticosteroids
  • H2-receptor antagonists
  • meperidine
  • sedative hypnotics

………revealed this list.

How often patients we are seeing who are older, from a Long Term Care or likely headed that way, are on one or more of these medications? Prednisone for COPD flare, H2 blocker for reflux, something to help with sleep in the noise and unfamiliar environment or medications for the aches and pain of old age.

What I do know is that delirium is terrible. Delirium is deadly. Delirium is a health systems problem that pills contribute to and do not make it better.  De-prescribing, the art of pairing back medications to the most essential, is a skill both PC and all providers need to cultivate.

________

DeRhodes KH. The Dangers of Ignoring the Beers Criteria—The Prescribing Cascade. JAMA Intern Med.Published online May 13, 2019. doi:10.1001/jamainternmed.2019.128ications

 

 

 

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