103. A psychiatric consultation was sought to evauate depression in a 56-year-old male with pancreatic cancer. His severe back pain was being well-treated with morphine. The patient was noted by the inpatient staff to be more withdrawn, disengaged, and quiet, making poor eye contact and sleeping most of the day. On examination, the psychiatric consultant found the man to be difficult to arouse and to be mildly confused and disoriented. His speech was slow and his thought process disorganized. He admitted to intermittently experiencing visual hallucinations that he had been too embarrassed to report earlier to the nursing staff. The man was diagnosed with a hypoactive delirium secondary to opioid medications. Which of the following is the most appropriate next step in his management?
A. Decrease dose of morphine.
B. Decrease frequency of morphine.
C. Discontinue morphine.
D. Do nothing.
E. Add an antipsychotic.
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Answer: E
Patients frequently experience some disorientation, impaired memory, and concentration loss as they become increasingly ill. Hypoactive delirium is a category of delirium with a clinical picture that is different from recognised hyperactive, hallucinatory state.
The patient is hypoactive and withdrawn, with varying levels of somnolence and unresponsiveness. These quiet, undemanding patients do not present any management problems; hence, the diagnosis of reversible condition is often overlooked, and it goes untreated. Hypoactive delirium should be diagnosed and treated as aggressively as hyperactive delirium. Antipsychotics alone can be effective in controlling symptoms when cognitive impairment and early delirium are present. The weight gain and type 2 diabetes seen in chronic psychiatric patients treated with antipsychotics are not a problem here, but dyskinesias, Akathisia, tremors, Parkinsonian rigidity, and rarely, tardive dyskinesia occur. Benzodiazepines, given alone, worsen delirium and are contraindicated, but they are useful adjuncts to antipsychotic drugs, in which cases they provide sedation for persistently agitated patients. Adding an antipsychotic is the best option in this stage, as this accomplishes treatment of his delirium.
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