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.()Pharmacotherapy for major depression in patients with other medical disorders requires special attention.Tricyclic antidepressants and SSRIs (although SSRIs are of less concern) can cause adverse cardiovascular effects in patients with heart disease or unstable blood pressure (eg, a tendency toward orthostatic hypotension).Both classes of drugs are reasonably safe when used properly in patients without serious heart disease.With longer hospitalization, the inability to respond to rehabilitative efforts and a patient's and family members' fears of chronic invalidism become proportionately greater.Hospitalized patients with depression often view themselves as hopeless; their hopelessness spreads to the staff members, who may pay less attention to them.Modifying the patient's environment may help (eg, involving the patient in group activities), but the depression itself also needs to be treated, usually with pharmacotherapy.DeliriumlDisturbance of consciousness with reduced ability to focus, sustain, or shift attentionllCognitive change (memory deficit, disorientation, language disturbance) or development of perceptual disturbance (hallucinations, delusions, illusions) not accounted for by preexisting, established or evolving dementiallRapid onset - usually hours to days and course tends to fluctuate during the course of the dayllEvidence that delirium is the direct physiological consequence of a general medical condition, substance intoxication or withdrawal, or medication side effectlDelirium is associated with poor patient outcomeslIncreased morbidity and mortality (several studies estimated 1 and 6 month mortality to be 14% and 22%, respectively - approx.twice that of patients without delirium)llThreefold increase risk of death after controlling for pre-existing co-morbidities, severity of illness, use of sedatives/analgesicsllIn hospital fatality rates estimated 25-33% (rates as high as MI, sepsis)llThree- to five-fold increase risk of nosocomial complicationslClassification based upon psychomotor activitylHyperactive delirium - approx.25% of cases - characterized by increased psychomotor activity and agitationllHypoactive delirium - approx.25% of cases - psychomotor activity is decreasedllMixed delirium - approx.35% of cases - psychomotor activity has hyperactive and hypoactive featuresllNormal - psychomotor activity normal - approx.15% of caseslTreatmentNon-pharmacologiclProvide quiet, well-lit room for patientllAvoid excessive noise, stimulationllEncourage familiar faces (family, caregivers) for reassurancellProvide orientationllCorrect sensory impairment(s)llCommunicate in a succinct, direct stylellAttentive nursing care, observationllDiscontinue non-essential medicationsllAvoid restraints (physical, pharmacological, urinary catheters, IVs)llGeriatric medicine consultationlPharmacologiclHaloperidol - use low dose - 0.25-0.50 mg po or 0.125-0.25 mg IV/IM with careful reassessment of patient prior to additonal dosingllPotential side effects - hypotension, sedation, akathisia (motor restlessness), anticholinergic effects, and extrapyramidal effectsllAtypical antipsychotics - risperidone, olanzapine, queitiapine - fewer side effects with similar efficacyllBenzodiazepines - reserve for alcohol and BDZ withdrawal deliriuml18lll
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