The consultant pharmacist - april, 2006

Case Study
Medication Sleuth: An Important
Role for Pharmacists in Determining
the Etiology of Delirium

A 65-year-old female, brought into the emergencydepartment by her husband, presented with altered mental status and increasingly aggressive behavior. Herhusband reported that she had been having trouble sleep-ing and had taken approximately five zolpidem 5-mgtablets to try to alleviate her insomnia. In the emergencydepartment, the patient was becoming increasingly com- Delirium is characterized by disturbances of consciousness, bative and was given multiple doses of haloperidol (a attention, cognition, and perception and is the most com- total of 15 mg intravenously [IV]) and lorazepam (a total mon reason for acute cognitive dysfunction in hospitalized of 6 mg IV) to try to calm her down. She was placed in elderly patients. Causes of delirium can be multifactorial, leather restraints and was transferred to the critical care and a careful medical and medication history can help unit for one-on-one care. She was started on ceftriaxone determine the underlying cause of behavioral disturbances.
2 g IV every 12 hours and acyclovir 1 g IV every eight A 65-year-old patient with a history of chronic pain, hours for potential encephalopathy, and KCl 10 mEq IV, insomnia, and multiple medical problems, who presented with altered mental status and aggressive behavior, is Her medical history included: diabetes mellitus with described. The patient had taken an overdose of zolpidem peripheral neuropathy, hypertension, migraines, anxiety, prior to admission, and she required chemical and physical hypercholesterolemia, hypokalemia, and chronic neck restraints and one-on-one care for safety. With time and pain. Her husband also reported a surgical history that washout of the zolpidem, the patient’s behavior did not included a total abdominal hysterectomy and a tonsillec- improve. On the second day of admission, medication tomy. Her outpatient medication regimen, as reported reconciliation of this patient’s medication profile helped to reveal a medication cause for this patient’s delirium. A pharmacist should be included early in the process of Orlistat 120 mg three times a day with meals obtaining a medication history. Recommendations for the Avandamet 2 mg/500 mg one tablet twice daily management of chronic pain and insomnia in the elderly KCl 40 mEq dailyHydrochlorothiazide 25 mg dailyPropranolol LA 80 mg dailyParoxetine 30 mg dailyEsomeprazole 40 mg daily Almotriptan 12.5 mg as needed for migraine This patient’s allergies/drug intolerances consisted of nausea with codeine and rash with sulfa-containingmedications.
Rebeccah J. Collins, PharmD, BCPS, is Assistant Professor,Virginia
Commonwealth University, School of Pharmacy, Geriatric Pharmacotherapy
Program, Richmond,Virginia.
For Correspondence: Rebeccah J. Collins, PharmD, BCPS,Virginia
Commonwealth University, School of Pharmacy, 410 North 12th Street,
P.O. Box 980533, Richmond,VA 23298-0533; Phone: 804-828-2296;
Fax: 804-828-8359; E-mail:
2006 American Society of Consultant Pharmacists, Inc. All rights reserved.
VOL. 21. NO. 4 APRIL 2006 THE CONSULTANT PHARMACIST Case Study: Medication Sleuth—Determining the Etiology of Delirium
Abnormal laboratory values on admission were serum was no prescription for zolpidem in her medication profile potassium 3.4 mmol/L and serum glucose of 204 mg/dL.
at the pharmacy.This list was reconciled with the list pro- All other chemistry and blood count values were within vided by the patient’s husband.The husband was not aware normal limits. A toxicology screen revealed the following that his wife had been taking Oxycontin and did not know results: negative for salicylate, ethanol, PCP, ampheta- where she could have gotten the zolpidem tablets.The mine, cannabinoids, opiates, barbiturates, and tricyclics; electronic record at her primary care physician’s office acetaminophen < 10 mcg/mL; and positive for benzodi- revealed that she was given zolpidem 5 mg tablet samples azepine. Urinalysis suggested a urinary tract infection (#15) at her last visit about one month prior to admis- (UTI), and a urine culture was pending. Blood culture sion. She was scheduled for a follow-up to reevaluate her results were negative. No acute findings were revealed neck and back pain and the effectiveness of Oxycontin and on a head CT. However, the patient was uncooperative, had missed her appointment one week prior.
and the study was of poor quality as a result of motion.
Vital signs on admission were: pulse 99 bpm, respiratory Medication-Related Problems of Highest Priority
rate 22, blood pressure 130/79 mmHg, and a tempera- Differential diagnosis of this patient’s combative behav- ior consisted of the following: zolpidem overdose, encephalopathy—viral versus bacterial, cerebral vascular The hospital family medicine team, which consisted of an attending physician, a third-year family medicine Zolpidem Overdose
resident, and a clinical pharmacist, saw the patient dur- Sedative-hypnotic agents commonly are used by older ing rounds. She was still restrained and combative, and people to promote sleep.These agents put older patients a nurse was providing one-on-one care.The patient was at risk for falls and hip fractures and can lead to changes also tearful and did not seem to understand that she in mental status.1 Zolpidem has been shown to offer no was in the hospital.The clinical pharmacist called the benefit in risk profile compared with other sedative patient’s pharmacy and obtained the following medica- agents such as benzodiazepines, antidepressants, and anti- convulsants.2 Doses should not exceed 5 mg in older patients.3 Our patient took approximately 25 mg in an effort to promote sleep and overcome withdrawal symp- Avandamet 2 mg/500 mg one tablet twice daily toms. Respiratory failure has been reported as a result of Orlistat 120 mg three times/day before meals zolpidem overdose.4 Other signs of zolpidem overdose include drowsiness, coma, and vomiting. Fortunately, our patient maintained adequate oxygen saturation and stable vital signs throughout her hospitalization.
Albuterol MDI two puffs every four hours as needed Medication History Discrepancies
A medication history was obtained from this patient’s husband without reconciliation from other sources.The clinical pharmacist was able to identify several discrepan- cies by contacting the patient’s pharmacy and physician’s office.Through compilation of the patient’s medication history, we identified the patient’s risk of opiate with- According to the pharmacy, she had missed a refill on drawal and allowed the medical team to treat the patient the atorvastatin and gabapentin, and she had been with- appropriately.The patient was given an immediate dose out her Oxycontin for approximately one week.There of morphine with subsequent improvement in behavior THE CONSULTANT PHARMACIST APRIL 2006 VOL. 21. NO. 4 Case Study: Medication Sleuth—Determining the Etiology of Delirium
and symptoms of psychosis.The patient was back to easily as in this case.Typically the symptoms of delirium baseline the next day, after receiving a standing order of resolve within 10 to 12 days; however, up to 15% of morphine, and was discharged on a taper of oral oxy- patients will have symptoms that persist up to 30 days codone/acetaminophen.The patient was scheduled for close follow-up with her primary care physician.
Oxycontin Withdrawal and Chronic Pain
Delirium and Combative Behavior
Between 20% and 40% of elderly patients will experi- Opioid addiction rates among patients with chronic, ence delirium during hospitalization.5 The American noncancer pain range from 3.2% to 18.9%. Addiction is Psychiatric Association’s Diagnostic and Statistical Manual, more common in patients with a history of drug or alco- 4th edition (DSM-IV), characterizes delirium by the hol abuse.9 While our patient did not have a history of abuse, she had been taking opioid agents for a number of There is a disturbance of consciousness, with reduced years for the management of her chronic neck and back ability to focus, sustain, or shift attention.
pain, and she had received a recent prescription for a There is a change in cognition or the development longer-acting formulation, Oxycontin. Her combative of a perceptual disturbance that is not better accounted behavior and altered mental status were likely a result for by a preexisting, established, or evolving dementia.
of withdrawal from this medication. She had failed to The disturbance develops over a short period of time follow up with her primary care physician and therefore (usually hours to days) and tends to fluctuate during the ran out of her medication.With reinstitution of an opioid agent, the patient’s behavior returned to normal. Close There is evidence from the history, physical examina- follow up and careful selection of pain medication for tion, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication,or medication side effect.
Impaired sleep may also accompany delirium and con- Delirium is characterized by disturbances of conscious- fusion.This patient displayed a disturbance of conscious- ness, attention, cognition, and perception. It is the most ness and a change in cognition that had developed over common reason for acute cognitive dysfunction in hospi- the period of a single day. Infection, including UTI, can talized elderly patients. Risk factors for delirium include be a risk factor for the development of confusion and dementia, medical illness, alcohol abuse, and increased altered mental status in the elderly.5 This patient was blood urea nitrogen level. Benzodiazepines and opioids given high-dose ceftriaxone for a presumed encephalopa- are also commonly associated with delirium.5 A pharma- thy, which also covered her UTI. Upon review of her cist’s review of a medication profile can detect possible medication history, we determined that she had taken an medication-related causes of delirium.Treatment of overdose of a sedative hypnotic and had been without a the underlying conditions causing delirium should be narcotic prescription for several days. She also had been priority; however, for the patient’s safety, a chemical or having sleep disturbances as is evidenced by the recent addition of zolpidem to her medication regimen. Her The Joint Commission on Accreditation of Healthcare combative behavior was treated by both chemical and Organizations (JCAHO), in its 2006 National Patient mechanical restraints. She had not improved with time as Safety Goals, requires an accurate and completely recon- would be expected if her behavior were entirely a result ciled medication list to be used across the continuum of of the overdose of zolpidem.The reinitiation of narcotic care.10 This initiative was established to try to reduce the therapy successfully brought the patient back to baseline, number of medication errors in the inpatient setting. A list and she was able to go home with close supervision.
should be compiled upon admission or at least within the The ceftriaxone and acyclovir were discontinued, and first 24 hours and should be maintained throughout the levofloxacin was ordered to cover the UTI.
patient’s hospital stay. Upon discharge, the list should be It is important to note that delirium may not resolve as communicated to the next health care provider. In our VOL. 21. NO. 4 APRIL 2006 THE CONSULTANT PHARMACIST Case Study: Medication Sleuth—Determining the Etiology of Delirium
patient case, a list was obtained from a family member.
be assessed for medical/psychiatric reasons for insomnia, The goal of medication reconciliation is to obtain patient such as uncontrolled pain, depression, anxiety, or med- medication information from multiple sources to ensure ication-related sleep disturbance. Pharmacists can edu- that an accurate and complete list is compiled. Refill histo- cate patients regarding nonpharmacological sleep mea- ries, physician office medical records, family members, sures and help detect medical/medication reasons for prescription vials, and previous admission data are all good sleep disturbances. Pharmacological agents, such as seda- resources for clarifying medication conflicts. Pharmacists tive-hypnotics, may be necessary for the treatment of are the obvious choice for making sure that patients are sleep disturbances.These agents put older patients at risk taking the appropriate medications. A 51% reduction in for falls and hip fractures and can lead to changes in medication errors has been observed when pharmacists mental status.1 Benzodiazepines are commonly used for were involved in obtaining medication histories.11 insomnia; however, these agents can impair sleep quality However, at most hospitals, pharmacists are not directly and cause many adverse effects.14 Nonbenzodiazepines, involved in obtaining medication-history information.12 A such as zolpidem and zopiclone, are also commonly used pharmacist should be on the hospital team that prepares a for sleep. Use of zolpidem in older people has been asso- standardized medication-reconciliation process.This prin- ciated with nearly twice the risk of hip fracture and ciple crosses all patient care settings. Communication therefore may not be a safe alternative for sleep.1 Long- between outpatient and inpatient pharmacists would term use of zopiclone may lead to dependence, but its greatly aid the medication reconciliation effort.
use has been associated with improvements in sleep pat- Chronic pain management in the elderly can be a chal- terns.15 Newer agents may prove to be more safe and lenge. Opioids are the current standard of care for the effective; however, actual risks associated with these treatment of chronic nociceptive pain.9 Longer-acting agents are unknown. Pharmacists should counsel patients agents are preferred for continuous, chronic-pain manage- and their family members on possible adverse effects and ment because they minimize the occurrence of withdraw- al and opioid-induced euphoria.13 Therefore, Oxycontinwas an appropriate choice for this patient’s chronic pain.
However, it is important to maintain close follow-up and Take-Home Points
monitor for adverse events. Community pharmacists can Acute delirium in the newly admitted older detect changes in a patient’s pain regimen and help moni- patient can be a result of multiple causes.
tor for effectiveness, as well as toxicity.
Chronic pain and insomnia management require The prevalence of sleep disturbances increases with appropriate drug selection and careful monitoring age.3 Nonpharmacological management should be exhausted before adding a pharmacological agent forsleep. Nonpharmacological tools for sleep include stimu- Medication history reconciliation is key in reducing lus control, sleep restriction, sleep hygiene, cognitive medication errors and decreasing health care costs.
therapy, and relaxation therapy. Also, the patient should THE CONSULTANT PHARMACIST APRIL 2006 VOL. 21. NO. 4 Case Study: Medication Sleuth—Determining the Etiology of Delirium
9. Nicholson B. Responsible prescribing of opioids for the management of 1.Wang PS, Bohn RL, Glynn RJ et al. Zolpidem use and hip fractures in older people. J Am Geriatr Soc 2001;49:1685-90.
10. Joint Commission on Accreditation of Healthcare Organizations. 2006 2. Rush CR, Baker RW,Wright K. Acute behavioral effects and abuse potential national patient safety goals. of trazodone, zolpidem, and triazolam in humans. Psychopharmacology 11. Bond CA, Raehl CL, Franke T. Clinical pharmacy services, hospital phar- 3.Wortelboer U, Cohrs S, Rodenbeck A et al.Tolerability of hypnosedatives in macy staffing and medication errors in United States hospitals.
older patients. Drugs Aging 2002;19:529-39.
4. Hamad A, Sharma N. Acute zolpidem overdose leading to coma and respira- 12. Gleason KM, Groszek JM, Sullivan C et al. Reconciliation of discrepancies tory failure. Intensive Care Med 2001;27:1239.
in medication histories and admission orders of newly hospitalized patients.
5. Korevaar JC, van Munster BC, de Rooij SE. Risk factors for delirium in Am J Health Syst Pharm 2004;61:1689-95.
acutely admitted elderly patients: a prospective cohort study. BMC Geriatrics 13. Adriaensen H,Vissers K, Noorduin H et al. Opioid tolerance and depen- dence: an inevitable consequence of chronic treatment? Acta Anaesthesiol Belg 6. American Psychiatric Association. Diagnostic and statistical manual, 4th ed.
14. Petit L, Azad N, Byszewski A et al. Non-pharmacological management of 7. Rockwood K.The occurrence and duration of symptoms in elderly patients primary and secondary insomnia among older people: review of assessment with delirium. J Gerontol 1993;48:M162-M166.
tools and treatments. Age Ageing 2003;32:19-25.
8. Sirois F. Delirium: 100 cases. Can J Psychiatry 1988;33:375-8.


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