Management of Postoperative Psychosis
Signs and tests of psychosis
Acute postoperative psychosis has been known for many years and was often blamed on anaesthesia. We now know this is not the case and multiple factors are involved. Delirium diagnosis remains a clinical diagnosis that requires a clinical assessment that can be structured using diagnostic criteria. The modified Richmond Agitation and Sedation Scale can be used as a tool to monitor for changes in mental status that could indicate the development of delirium. The key lies in addressing the underlying cause/causes of delirium, which often involve medical conditions or medications. Other attempts have been made to use standard classification criteria for mental illness, employed in psychiatric medicine, to define POND. While this can be done with children, for example, its usefulness in one study is questionable as spontaneous recovery occurred in all patients and no patient suffered delayed discharge from the day care unit. With adults delirium is well defined and is described in the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV–TR)
Laboratory tests, beyond those already mentioned, offer little additional diagnostic information.
The prognosis will depend on the co-morbidities and the development of complications, but the majority of patients who develop an acute confusional state will, in time and with good management, return to their pre-morbid state.
In high-risk patients prevention may be achieved by providing a consistent environment with readily available points of reference. These may help to reduce the degree of confusion. Environmental factors are particularly important in the treatment of acute confusional state and the following factors are helpful in shortening the period of confusion.
- Continuity of care personnel i.e. the same nurse/doctor whenever possible
- Clear concise communication
- Repeated verbal reminders of time, place and person
- Clock, calendar, TV, newspaper, radio readily accessible as a means of orientating in time
- Bedside lighting available and left on at night
- Simplify the environment, single room when available, reduce noise levels, remove unnecessary equipment
- Correct any sensory impairment by ensuring the patient is wearing hearing aid/glasses/false teeth etc.
- Allow maximum periods of uninterrupted sleep
- Allow patient to become involved in self-care regime, decide level of analgesia etc.
- Encourage mobilisation and increase activity levels
The implications of constantly moving patients from ward to ward in the interests of efficient bed management are clear.
Medical Treatment using drugs and other therapeutic measures
Drug treatment is most effective only if used in conjunction with the environmental measures above, or otherwise may in some instances worsen the confusion. Early intervention with drugs when required is associated with lower overall drug use and better eventual outcome.
- The underlying causes must be treated first e.g. infections may require antibiotics, electrolyte disturbances corrected
- A drug review, including herbal remedies, should be undertaken. Drugs are implicated in 10-20% of cases. All drugs are capable of producing the state, but some are much more likely to produce problems e.g. narcotics, opiates, benzodiazepines and drugs with anticholinergic activity. This last group of drugs is commonly used to treat a variety of unrelated conditions. These include: diarrhea, overactive bladder, and incontinence
- Antipsychotic agents (major tranquilizers) such as chlorpromazine or haloperidol are commonly used as minor tranquilizers such as benzodiazepines (valium) may induce the symptoms themselves. Low doses of haloperidol are preferable to other agents due to a lower side effect profile, but may be ineffective. Droperidol may be used for its speed of onset and if increased sedation is required. The smallest effective dose is the correct dose.
- Olanzapine and respiridone have been used as alternatives to the major tranquilizers (low dose haloperidol (< 3.0 mg per day) they may be less sedating and have fewer side effects. If it is felt that treatment with a benzodiazepine would be beneficial, then lorazepam is the drug of first choice due to its rapid onset of action and low side effect profile.
Complications of acute confusional state or post-operative psychosis can result in increased morbidity and increased length of hospital stay (LOS) and use of care facilities on discharge if not recognized and treated early. Common problems occur as a result of falls, injury during periods of agitation, increase in problems from poor mobility secondary to sedation e.g. chest infections, pressure sores, pulmonary emboli and therefore early intervention with environmental factors+/- appropriate drug therapy is important in preventing secondary problems.
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