Hypnotics delirium

Glassification of Substance-Related Disorders. The DSM-IV classification system (1) divides substance-related disorders into two categories (/) substance use disorders, ie, abuse and dependence and (2) substance-induced disorders, intoxication, withdrawal, delirium, persisting dementia, persisting amnestic disorder, psychotic disorder, mood disorder, anxiety disorder, sexual dysfunction, and sleep disorder. The different classes of substances addressed herein are alcohol, amphetamines, caffeine, caimabis, cocaine, hallucinogens, inhalants, nicotine, opioids, phencyclidine, sedatives, hypnotics or anxiolytics, polysubstance, and others. On the basis of their significant socioeconomic impact, alcohol, nicotine, cocaine, and opioids have been selected for discussion herein. 

Paraldehyde, a miscellaneous sedative and hypnotic, may be used to treat delirium tremens and other psychiatric conditions. In addition, some barbiturates are used as anticonvulsants (see Chap. 28). 

Other sedative-hypnotic medications, such as barbiturates, may play a useful role in severe withdrawal from this group of drugs. For example, in a case series of GBL withdrawal, use of intravenous pentobarbital in the range of 1-2 mg/kg/hour lowered the total requirement for intravenous lorazepam (Sivilotti et al. 2001). Antipsychotic medications are often used to reduce psychotic agitation. However, because antipsychotic medications lower the seizure threshold and may contribute to loss of central control of temperature leading to hyperthermia or neuroleptic malignant syndrome (NMS), they are not indicated as first-line medications for GHB withdrawal delirium (Dyer and Roth 2001 McDaniel and Miotto 2001 Sharma et al. 2001). If anti-... 

Uni 1ke other drugs of abuse, the diagnosis of PCP intoxication is often difficult because of the wide spectrum of clinical findings that occurs with this drug. PCP toxicity sometimes can be mistaken for delirium tremens, acute psychiatric illness, sedative/ hypnotic overdosage, amphetamine intoxication, or sedative/ hypnotic withdrawal syndromes. 

Sedative-hypnotics Functional Ul due to immobility, delirium, sedation... 

Information about prescription drag use alcohol or other substance use family medical history and history of trauma, depression, or head injury should be obtained. It is important to rule out medication use as a contributor or cause of symptoms (e.g., anticholinergics, sedatives, hypnotics, opioids, antipsychotics, and anticonvulsants) as contributors to dementia symptoms. Other medications may contribute to delirium, e.g.,... 

Sedative hypnotics Functional incontinence caused by delirium, immobility... 

Sedative-hypnotics Excessive sedation, delirium, gait disturbances... 

Knowing the differential pharmacokinetics for a class of drugs allows the clinician to choose specific members to either achieve a faster onset or a delayed offset of action (13, 14, 17, 18). For example, lorazepam is rapidly absorbed from the gastrointestinal tract into the systemic circulation and from there distributed into the brain. In contrast, oxazepam, the most polar BZD, is slowly absorbed from the gastrointestinal tract. Even after oxazepam is in the systemic circulation, it slowly enters tissue compartments, including the brain, during the distribution phase. Unlike lorazepam, oxazepam is not available in either the intramuscular or intravenous formulations. Thus, lorazepam would be preferable to achieve acute control of alcohol withdrawal (e.g., delirium tremens), whereas oxazepam would better stabilize a dependency-prone patient on sedative-hypnotics, because it does not cause the euphoria seen with the more rapidly absorbed members of this class. 

Long-acting drugs such as chlordiazepoxide and diazepam and, to a lesser extent, phenobarbital are administered in progressively decreasing doses to patients during withdrawal from physiologic dependence on ethanol or other sedative-hypnotics. Parenteral lorazepam is used to suppress the symptoms of delirium tremens. 

Withdrawal from sedative-hypnotics may be accompanied by a delirium that can be life threatening. In severe withdrawal, seizures, visual, tactile, or auditory hallucinations may occur. 

The extensive clinical use of triazolam has led to reports of serious central nervous system effects including behavioral disinhibition, delirium, aggression, and violence. While behavioral disinhibition may occur with sedative-hypnotic drugs, it does not appear to be more prevalent with triazolam than with other benzodiazepines. Disinhibitory reactions during benzodiazepine treatment are more clearly associated with the use of very high doses and the pretreatment level of patient hostility. 

Benzodiazepine (BZ) intoxication is manifested as slurred speech, poor coordination, swaying, drowsiness, hypotension, nystagmus, and confusion. Signs and symptoms of BZ withdrawal are similar to those of alcohol withdrawal, including muscle pain, anxiety, restlessness, confusion, irritability, haJlucinations, delirium, seizures, and cardiovascular collapse. Withdrawal from short-acting BZs (e.g., oxazepam, lorazepam, alprazolam) has an onset within 12 to 24 hours of the last dose. Diazepam, chlordiazep-oxide, and clorazepate have elimination half-lives (or active metabolites with elimination half-lives) of 24 to greater than 100 hours. So, withdrawal may be delayed for several days after their discontinuation. Sedative-hypnotic dependence is summarized in Table 73-2. 

Benzodiazepines (if alcohol/sedative-hypnotic withdrawal-induced delirium)... 

Statements on the possibility of tolerance to the emetic effect of apomorphine are conflicting. Addiction to it seems never to have been reported. Apomorphine has been recommended as a hypnotic in alcoholic delirium. Narcosis caused by morphine seemed to be reenforced Avith apomorphine (1). 

It is one of the oldest hypnotics. The drug is usually employed in delirium tremens, status epilepticus and in patients undergoing withdrawal therapy for alcoholism. A certain portion of the administered drug is exereted through the lungs. 

Other Paraldehyde Class IV Exhaled via the lungs strong odor and disagreeable taste seldom used has been used to control delirium tremens (DTS) in alcoholics can be used for drug poisoning Status epilepticus and tetanus to control convulsions Pregnancy category C, PB UK half life 7.5 hours Sedative PO 5-10 mL q4—6h PRN in water or juice maximum dose of 30 mL Hypnotic PO 10-30 mL h.s. 

The corresponding 6,7-epoxide, scopolamine (17), is produced only in young leaves. This alkaloid inhibits germination of the seeds of several plants and inhibits growth of the radicle in Lepidium and Lactuca. Scopolamine has been used as a premedication prior to surgery and as a powerful hypnotic in the treatment of the delirium tremens (DTs) (Cordell, 1981). Scopolamine also is widely used to treat motion sickness (Tyler et al., 1981). This alkaloid is a feeding deterrent for several insects (Wink, 1993). 

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