practice partner
recommendations:
Recommendation: Health-care
professionals are reminded that
acute delirium is a common clinical
syndrome in hospitalized adults,
particularly older adults. Delirium
has a significant morbidity
and mortality attributable to
it that is independent of the
underlying cause. All health-care
professionals working in a hospital
setting should be knowledgeable
in the prevention and recognition
of the clinical syndrome of acute
delirium.
Recommendation: Health-care
professionals are reminded that
the investigation and management
of acute delirium in hospitalized
patients requires a coordinated,
interprofessional team approach.
Health-care teams in acute
care hospitals should have
interprofessional clinical protocols
for delirium, which include nonpharmacologic and pharmacologic
management strategies.
Recommendation: Physicians
who are prescribing treatment
for hospitalized elders with
delirium should ensure that
they are familiar with commonly
cited literature regarding
pharmacologic management
of delirium. In particular, use of
“prn” medications for treatment
of agitation is rarely indicated
or helpful. If needed, clear
guidelines as to when to use a
“prn” medication should be written
and followed. Physicians should
also routinely access the expertise
of colleagues for this purpose,
40
including pharmacists, and
specialists in geriatric medicine
and psychiatry.
Recommendation: Practitioners
prescribing and administering
narcotics to the elderly should
follow standard practice
guidelines for the recognition
and management of narcoticinduced side effects, including
narcotic toxicity and constipation.
Constipation should be an
anticipated side effect of narcotic
use in elders, and should be
managed proactively, not reactively.
Recommendation: Health-care
professionals should be reminded
that fentanyl transdermal should
not be prescribed as a first
narcotic in a narcotic-naive
patient. Hospital pharmacies
should consider having a
pharmacist review all prescriptions
for fentanyl transdermal to ensure
that it is a progression from shortacting narcotics or an ongoing
prescription, and not a first
narcotic prescription.
Recommendation: Health-care
professionals practising in acute
inpatient care should have regular
team meetings to discuss and
document plans of care for all
patients. This is particularly
important for complex, clinically
challenging cases. Physicians, as
a key member of the team, should
attend these regular meetings as
part of their duty of care to the
hospitalized patients.
which is a slowly progressive change
in cognition that develops over
months or years, and where behavioural disturbances arise slowly and
over time.
The treatment of a delirium
versus a stable, slowly progressive
dementia and their complications,
are vastly different. The symptoms
of delirium continued for her entire
stay in hospital. Her persistent and
ongoing delirium was probably
caused by multiple factors, including the high and increasing doses of
narcotics, constipation and bowel
obstruction, pain, dehydration,
hospital environment, grief over
loss of her recently deceased daughter, and restraints (i.e., side rails and
a chair with table). Many of these
contributing factors could have
been addressed, had the delirium
been recognized.
The Committee stated that the
care of this patient was lacking an
overall, cohesive approach and plan.
The management of the patient’s
pain was also of concern to the
GLTCRC as no clear etiology for
her pain was ever established. More
importantly, the prescription of
increasing doses of a transdermal
narcotic as the first step after plain
acetaminophen was problematic.
“Fentanyl transdermal should not
be prescribed to a narcotic-naive
patient, especially an elderly patient. A better choice for the elderly
is to start with short-acting hydromorphone, which has less likelihood to cause delirium in elders,”
stated the report.
Once a proper dose of shortacting drug is established, conversion to long-acting can be made if
the cause of the pain is ongoing. As
Dialogue Issue 2, 2016
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