Kelly C. Rogers, PharmD, FCCP

• Professor, Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, Tennessee

https://academic.uthsc.edu/faculty/KellyCRogers.html

Fi worsen hypertropia allergy symptoms in babies buy 25 mg promethazine with visa, since these ocular counter-roll nally allergy shots joint inflammation generic 25 mg promethazine with mastercard, increased right hypertropia on ipsilateral head mechanisms are intact allergy symptoms virus purchase generic promethazine. The superior oblique arises fourth nerve palsy allergy testing raleigh nc order promethazine 25mg free shipping, because of weakened intorsion; in from the orbital apex, passes through a fibrocartilagi contrast, intorsion of the hypertropic eye occurs in nous trochlea just inside the superior medial orbital skew deviation, due to decreased stimulation of the rim, and then inserts on the superior lateral aspect of inferior oblique subnucleus. Its main action, deviation is mitigated in the supine position in skew therefore, depends upon the position of the eye: deviation, but not fourth nerve palsy, relates to the when the eye is abducted, the superior oblique is a strong intorter, and when the eye is adducted, it is a fact that utricular inputs depend upon head position; depressor. Its tertiary action is abduction of the globe the utricular imbalance that causes a skew deviation in depression. What is the differential diagnosis for a fourth nerve palsy due to overaction of the ipsilateral inferior oblique, and what testing would you pursue The precise etiology of congenital fourth nerve palsy is unclear but may include hypoplasia of the nucleus, birth trauma, anomalous muscle insertion, muscle fibrosis or adhesion, or structural abnormalities of the ten don. There is often periorbital aching pain on presentation, and excellent spontaneous recovery is expected over several months. Less frequent causes of fourth nerve palsy in clude midbrain hemorrhage or infarction, schwan noma, aneurysmal compression, meningitis, demyelination, giant cell arteritis, hydrocephalus, and herpes zoster ophthalmicus. The trochlear nerve is the longest changes related to resection of a hemangioblastoma and thinnest of all the cranial nerves, coursing along within the fourth ventricle. The etiology of his right the free edge of the tentorium through the prepon fourth nerve palsy was most likely intraoperative tine cistern, where it is vulnerable to crush injury. Occlusion of the af cal fusional amplitude that reduces the likelihood of fected eye (or, if diplopia occurs only in down-and postoperative diplopia. Al the patient had 1 diopter right hypertropia in pri ternatively, base-down prism over the affected, hy mary and eccentric gaze, measured by Maddox rod pertropic eye may alleviate diplopia (by shifting the testing. Head capable of providing a fixed amount of correction for position-dependent changes in ocular torsion and vertical misalignment. A new clas fail, as long as measurements of misalignment have sification of superior oblique palsy based on congenital been stable over several months. Next, increased right hypertropia in contralateral gaze narrows the possibilities to right superior oblique or left superior rectus weakness. Fluores cein angiogram (B, D) shows optic nerve hyperfluorescence bilaterally (arrows) with left stippled hypofluorescent spots repre senting choroidal leakage with nonfilling infiltrates (D, asterisk). He denied any symp lower back radiating into both legs and an associ toms of raised intracranial pressure including head ated band-like sensation around his waist. There was subjective decrease in light touch acuity was 20/20 in the right eye and 20/150 in the and pinprick sensations up to the midshin level bilat left. Ophthalmoscopy showed marked bi Questions for consideration: lateral optic disc swelling (figure 1, A and C) and macular edema in the left eye. There was Differential diagnosis includes chronic meningitis no evidence of venous sinus thrombosis or abnormal due to fungal infections, which can cause subacute meningeal enhancement. Questions for consideration: Bilateral simultaneous or sequential optic neurop athy due to inflammation (as in neuromyelitis optica, 1. Therefore, given the lateralizing ciated with these conditions is typically much higher defects in visual acuity, visual field sensitivity, and than that observed in this case. In addition to the optic disc edema, there was a To better tailor further workup, reconsideration slightly creamy appearance to the choroid around the of the localization of the problem is important. Pro Question for consideration: cesses affecting the afferent visual pathway posterior to the chiasm should produce visual field deficits that 1. The dif the treatment for neurosyphilis and ocular syphilis ferential diagnosis of this appearance is limited given is similar. When as slower than cell count and may even persist in those with more advanced immunosuppression. Williams: sory ataxia and lancinating pains, are seen in the late critical review of the manuscript and review of the literature. Williams serves on scientific advi However, about 10% of patients with syphilis de sory boards for Bausch Lomb, Novartis, Regeneron Pharmaceuticals, Inc. Neurosyphilis: a historical perspective and the diagnosis of syphilis is based on serology. Sexually transmitted diseases treat sensitivity, as up to 70% of neurosyphilis patients test ment guidelines. Syphilis tests in diagnostic and therapeutic deci cumstances, the fluorescent treponemal antibody sion making. She re ahead binocular acuity was 20/20, but only 20/50 in ported 3 weeks of progressive clumsiness of the right lateral downgaze due to oscillopsia. The eye move Address correspondence and limbs, weakness of the right leg, and an unsteady gait. Her neurologic exam There was no rigidity or stiffness of limb or axial ination in 1998 had revealed downbeat nystagmus, a muscles. Type I diabetes mellitus was diagnosed sev There was right-sided dysmetria, dysdiadochokine eral months after this initial episode. The pa In the 1980s, a low vitamin B12 level (value un tient could sit upright unsupported but required known) was thought to have been an incidental finding; assistance to ambulate due to weakness and ataxia. A grandparent had type I diabetes, but no roiditis was diagnosed several months after the sec relatives had neurologic disorders. Question for consideration: General medical examination had normal results, including the absence of vitiligo. The hemiataxia and leg weakness may lo changed at 1 month, 8 months, and 2 years (no re calize to the pontocerebellar and corticospinal stricted diffusion, abnormal enhancement, or atrophy). While downbeat nystagmus, Our patient had a subacute, apparently recurrent, often seen in conjunction with saccadic pursuit sporadic ataxia. What is the differential diagnosis of a sporadic ataxia with also occur with pontomedullary paramedian tract or without brainstem features Allelic to episodic ataxia 2, spinocerebel uncommon in mass lesions and infectious/postinfec lar ataxia 6 occasionally presents with episodic ataxia. Thyroperoxidase/ progressive/monophasic forms of demyelinating dis thyroglobulin, pancreatic islet cell, and gastric pa ease; and immune disorders. Questions for consideration: the recurrent ataxias include the episodic ataxias, relapsing multiple sclerosis, and strokes. Less likely diagnostic possibilities stiff-limb syndrome); and potential for immuno include recurrent demyelination, stroke, Bickerstaff therapy responsiveness. The clinical course was usually subacute but honoraria for educational activities from Teva Pharmaceutical Industries Ltd. Associated autoimmune conditions/marker lar ataxia, late-onset insulin-dependent diabetes 4. Seizures may be due to idiopathic epilepsy syndromes or can be symptomatic of Dizziness. The term dizziness can have diverse mean underlying neurologic or systemic pathology. Each ings and may represent vertigo, light-headedness, symptom therefore requires a detailed history, neu unsteadiness, or even anxiety. Dizziness can occur rologic examination, and evaluation to distinguish in the setting of benign inner ear conditions.

Pain Quality: biphasic with Usual Course sharp allergy forecast in houston tx purchase promethazine on line, triggered paroxysms and dull throbbing or burn Progression allergy testing york hospital purchase promethazine online, usually very gradual allergy treatment sample buy cheap promethazine on line. Social and Physical Disabilities Social and Physical Disability Impaired mastication and speech allergy treatment london discount promethazine amex. Idiopathic trigeminal neuralgia, secondary trigeminal neuralgia from intracranial lesions, postherpetic neural Summary of Essential Features and Diagnostic Cri gia, odontalgia, musculoskeletal pain. Differential Diagnosis Acute Herpes Zoster (Trigeminal) Syndrome is usually unmistakable. Time Pattern: pain usually precedes the onset of herpetic eruption by System one or two days (preherpetic neuralgia); may develop Trigeminal nerve. Time Pattern: Constantly the distribution of the ophthalmic distribution of the present with exacerbations. Pain Quality: sharp, lancinating, shocklike Signs and Laboratory Findings pains felt deeply in external auditory canal. Hypoesthesia to touch, hy poalgesia, hyperesthesia to touch, and hyperpathia may Signs and Laboratory Findings occur. Usually follows an eruption of herpetic vesicles which appear in the concha and over the mastoid. Social and Physical Disability Pathology Severe impairment of most or all social activities due to No reported case with pathological examination. Differential Diagnosis Summary of Essential Features and Diagnostic Cri Differentiate from otic variety of glossopharyngeal neu teria ralgia, which does not have herpetic prodromata. X2 table cutaneous pain in distribution of the ophthalmic division of the trigeminal associated with cutaneous scarring and history of herpetic eruption in an elderly patient. Neuralgia of the Nervus Differential Diagnosis Intermedius (11-7) the syndrome is usually characteristic. Pain Quality: sharp agonizing electric shock-like stabs of pain System felt in the ear canal, middle ear, or posterior pharynx, the sensory fibers of the facial nerve. Precipitation System Pain paroxysms can be triggered by non-noxious stimu Peripheral and central mechanisms involving glosso lation from the posterior pharynx or ear canal. Or from surgical side, also by swallowing and by ingestion of cold or acid procedures: microsurgical decompression of the nervus fluids. Time Pattern: episodic bouts occurring spontaneously several times daily or triggered by Usual Course any of above mentioned stimuli. Intensity: very severe, Recurrent bouts over months to years, interspersed with interferes with eating. Signs and Laboratory Findings Pathology the important and only sign is the presence of a trigger Most patients have impingement on the nervus interme point, usually on fauces or tonsil; sometimes it may be dius at its root entry zone. Differential Diagnosis Must be differentiated from tic douloureux involving the Social and Physical Disability Vth nerve, glossopharyngeal neuralgia, and geniculate Only as related to pain episodes. May be confused with Definition trigeminal neuralgia limited to mandibular division. X8b Page 64 Neuralgia of the Superior Differential Diagnosis Glossopharyngeal neuralgia, carotidynia, local lesions. X8e Paroxysms of unilateral lancinating pain radiating from the side of the thyroid cartilage or pyriform sinus to the angle of the jaw and occasionally to the ear. May be a variant of glossopharyngeal System neuralgia, which has also been called vago-glosso Nervous system. Perhaps related to increased muscle area of the thyroid cartilage radiating to the angle of activity in cervical muscles. Time tumor, herniated cervical disk, uncomplicated Pattern: episodes last weeks or months with a continuous or flexionextension injury, metastatic neoplasm at the base intermittent pattern. Such findings are: thin caliber, segmental narrowing, and even occlusion and opening of new vessels. X3a of minor stimuli within the innervation zone of the Vth cranial nerve but also by neck movements. Cortisone may Repetitive paroxysms of unilateral short-lasting pain possibly be of some avail. Site the ocular and periocular area, occasionally with spread Essential Features to the fronto-temporal area, upper jaw, or roof of the Shortlasting, unilateral paroxysms of ocular pain, associ mouth. In some cases, attacks may ing late stage and moderate involvement of the opposite be triggered mechanically. X8j Page 67 and Schlezinger type cases, nevertheless, probably References originate in or close to the area of pathology of type I Bussone, G. Age of Onset: usually headache attacks with tearing and conjunctival injection: the middle-old age. Time Pattern: there is a relatively longlasting pe Cephalalgia, 9 (1989) 147-156. No specific ther apy is known at present and no special benefit occurs Site with indomethacin. In the occa sional case, such periods may be repeated one or more Main Features times. Hemicrania continua is also a syndrome: sweat gland and pupillary responsiveness in two diagnostic possibility; hypothetically, orbital space cases with a probable 3rd nerve dysfunction, Cephalalgia, 9 occupying disorders (but they hardly give rise to Hor (1989) 63-70. Affects the majority of the popu frequently, but not in all cases, associated with muscle lation. Site Frontal, orbital, fronto-occipital, occipital, nuchal, or Pathology whole scalp area. X7a Main Features Prevalence: Often diagnosed; even approximate preva References lence is unknown, mainly because of lack of precise Kudrow, L. Page 69 Start: Gradual emergence as mild, diffuse ache or un Pathology pleasant feeling, intermittent at first, increasing with Unsettled. In a proportion of cases, exacerbations with ad may, however, also be present in patients with migraine. Occurrence and Duration: Every day controls with patients, in particular after appropriate or most days, for most of the day. Some describe tight band feeling or chronic headache, with fewer accompanying features gripping headache. Precipitants and Exacerbating Factors Emotional stress, anxiety and depression, physical exer Differential Diagnosis cise, alcohol (which may also have the opposite effect). Page 70 splints and psychotherapy, has not been shown to be Temporomandibular Pain and superior to placebo. Complications Possible degenerative joint disease, depression and anxi Site ety, drug dependence. In some intractable cases wide Temporomandibular, intra-auricular, temporal, occipital, spread diffuse aching facial pain develops. Social and Physical Disability System Interference with mastication and social and vocational Musculoskeletal system. Trauma is known to be re mandibular pain and dysfunction have an age range of 5 lated to a minority of cases. Combinations of Muscle tenderness; temporomandibular joint clicking; aching and severe exacerbations may also occur. Time difficulty in opening the jaw and sometimes deviation on Pattern: the pain may be continuous by day or brief. It is opening; a dull ache or severe episodes associated with often worse on waking. Differential Diagnosis Clicking of the joint or popping noises in the ears are Degenerative joint disease, rheumatoid arthritis, trau frequently present. X8a palpation of the muscles of mastication; clicking or pop ping at the joint on auscultation or palpation; changes in References the ability to occlude the teeth fully. The clinical significance of disk displacement and its rela tionship to the syndrome are not established.

The athlete does not present apparent clinical contraindications to practice andhave examined the above-named student and completed the preparticipation physical evaluation allergy medicine good for kittens purchase genuine promethazine on-line. The athlete does not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above allergy testing methods discount promethazine 25mg amex. A copy of the physical exam is on record in my of ce and can be made available to the school at the request of the parents allergy testing grand rapids order generic promethazine on line. If condi ariseaftertheathletehasbeenclearedforparticipation allergy treatment in kids buy promethazine 25mg free shipping,aphysicianmayrescindtheclearanceuntiltheproblemisresolvedandthepotentialconsequencesarecompletelyexplainedtions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians). A copy of the physical exam is on record in my offce and can be made available to the school at the request of the parents. If conditions arise after the athlete has been cleared for participation, the physician may rescind the clearance until the problem is resolved and the potential consequences are completely explained to the athlete (and parents/guardians). Permission is granted to reprint for noncommercial, educational purposes with acknowledgment. This Seizures: What are they and Why are disturbance in the electrical rhythm of the brain primarily they Important Generalized Involves whole body shaking and Seizures electrical disturbances of the majority of the cerebral cortex or face, which refect this synchronous rhythm stimu Focal Seizure Involves electrical disturbance of one lating nerve cells responsible for controlling the limbs. Can involve only jerking of one consciousness since the nerve cells in the brain cannot part of the body such as an arm, leg function normally. Con the most well known type of seizure is the generalized sciousness is not afected. During this brain, manifesting as subtle changes type of seizure, in typically in consciousness such as staring epi the electrical sodes. Usually short (~5-20 sec) but rhythm of the developing children, can occur many times per day (some whole brain is times up to 100). Most seizures tend to resolve Myoclonic Seizures A type of generalized seizure that ap generalized sei within a year or two pears as quick short jerks of the arms, zures only last legs, body or head. They are usually a few minutes of starting medications associated with epileptic syndromes. Syndrome graphic seizures in the language area of should be noted the brain that shows up as language re that the classif gression after three years of age without cation of seizure other symptoms of autism. Children can have autistic symp Looks Can Be Deceiving toms but this syndrome is very rare. An suspected of having seizures and carefully determine if electroencephalogram is key to diagnosing seizures the episodes are seizures or not since there can be very since seizures are defned by specifc abnormal electri diferent ways of treating seizure and non-seizure events. Can cognition, and learning and may be associated with involve tightening of the muscles. The presence of these fndings suggests that there is an discharges) increased risk for seizures. Seizure A seizure occurs when epileptiform discharges successively occur in a rhythmic fashion for several seconds. Focal Epileptiform discharges can occur only in one part of the brain (focal) as compared to being wide Discharges spread throughout the brain (generalized). Photic Stimulation Photic stimulation using a fashing light can evoke epileptiform discharges which can be helpful for determining a propensity of having seizures. Focal Slowing Slowing of the brain waves in one portion of the brain suggests dysfunction of the brain in a par ticular region. Generalized Slowing Slowing of the entire brain suggests generalized dysfunction of the brain. This can be seen after a seizure or can be due to metabolic disturbances of the brain. Hemispheric Asymmetries Brainwaves should be similar in size and character on both sides of the brain. Asymmetries of the brain waves suggest that one side of the brain is dysfunctional. Abnormal Sleep Specifc brainwaves occur during sleep and sleep is associated with a progression through specifc Architecture sleep stages. Abnormalities afecting sleep brain waves can indicate abnormalities of brain function. Unprovoked indicates that the seizures were not caused by a fever, trauma, infection, or metabolic illness. To many parents, epilepsy is a scary diagnosis but it is actually relatively common even in typically developing children. Epilepsy and Autism Autism is associated with an increased risk of epilepsy Causes of Epilepsy in Autism and almost every type of seizure has been described the close association between autism and seizures suggests in autism. The reason for a high prevalence of seizures is not well under have not been well studied. Children with autism deserve an overnight electroencepha the efectiveness and tolerability of treatment for seizures logram. In general, such treatments should only be used as add-on therapy to treatment is often a trial-and-error process. There is a significant need for research in seizures and epilepsy in have adverse efects, resulting in additional medications autism. Still, many times addressing underlying immune and/or metabolic abnormalities can be helpful for seizure control. Improving Seizure Control Factors that afect general health can also worsen seizures, so improving these factors can improve seizure control. Other medical conditions, such as allergies, when not con the use of cannabis has become of particular inter trolled well, can be associated with increased seizures. It is important to understand that cannabis contains hundreds of phy When seizures are refractory to standard treatments tocannabinoids, some of which may have medicinal and general health has been optimized, there are sev properties. For example, compliance with a 3x/day medi types-seizures/new-terms-and cation is much lower than a 1x/day medication, even in the best patients. When the number concepts-seizures-and-epilepsy of medications prescribed increases, the ability to implement the treatments is decreased. Autism: Many times patients are reluctant to tell their doctors if they are having trouble implement From Biology to Behavior. Hufngton ing the treatment and doctors tend to assume that the treatment is going as planned if the Post; 2014. Finding a treatment regimen that the family can implement is behavior-to-biology b 7882420. Many metabolic disorders associated with autism are disorder with seizures: an on-line associated with seizures. A review of traditional and novel treatments for seizures in autism spectrum disorder: fndings a higher incidence of adverse effects. An American Red Cross instructor is a member of a select group of trained and authorized individuals who reflects the standards and ideals of the American Red Cross. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission from American Red Cross National Headquarters, Preparedness and Health and Safety Services. American Red Cross certifcates may be issued upon successful completion of a training program, which uses this manual as an integral part of a course. By itself, the material in this manual does not constitute comprehensive Red Cross training.

Benzodiaz epines have been associated with sedation allergy symptoms chills discount promethazine 25mg mastercard, behavioral disinhibition new allergy medicine 2014 purchase 25mg promethazine mastercard, amnesia allergy medicine restless leg syndrome discount promethazine 25mg on line, ataxia allergy testing las vegas discount generic promethazine uk, respiratory depression, physical dependence, rebound insomnia, withdrawal reactions, and delirium. Benzodiazepines should also be avoided, or used with caution, in patients with respiratory in sufficiency. For patients who have hepatic insufficiency or are taking other medications metab olized by the cytochrome P450 system, benzodiazepines that are predominantly metabolized by glucuronidation (lorazepam, oxazepam, and temazepam) should be used when a benzodiaz epine is required. Few studies have investigated the optimal dose of benzodiazepines for the treatment of de lirium. However, the dose must be carefully considered, given the possibility that benzodiaz epines may exacerbate symptoms of delirium. In cases of delirium due specifically to alcohol or sedative-hypnotic withdrawal, higher doses of benzodiazepines and benzodiazepines with long er half-lives may be required. In a report of a case series of 20 critically ill cancer patients for which benzodiazepines and antipsychotics were administered together, Adams et al. In some cases of severe agitation, the eventual doses of both medications have been quite large. Cholinergics a) Goals and efficacy Anticholinergic mechanisms have been implicated in the pathogenesis of many medication-in duced deliriums. In addition, anticholinergic mechanisms may be involved in delirium from hypoxia, hypoglycemia, thiamine deficiency, traumatic brain injury, and stroke (49). However, cholinergic medications have been used in a very limited fashion to treat delirium, almost ex clusively in cases of delirium clearly caused by anticholinergic medications. Physostigmine, a centrally active cholinesterase inhibitor, has been used most often, with tacrine and donepezil re ceiving less attention. In one prospective study (92), physostigmine reversed delirium among 30 patients in a pos tanesthesia recovery room, in whom either atropine or scopolamine had caused the delirium. In four single case reports of delirium diagnosed by clinical interviews, physostigmine reversed the delirium resulting from ranitidine (93), homatropine eyedrops (94), benztropine (95), and meperidine (96). In a single case study (97), tacrine reversed delirium induced by anticholinergic medication. Newer cholinesterase inhibitors with fewer side effects than tacrine have not been studied for treatment of delirium. Physostig mine can cause seizures, particularly if intravenous administration is too rapid (98). Tacrine has Treatment of Patients With Delirium 25 Copyright 2010, American Psychiatric Association. Doses that have been used in studies of de lirium have included intravenous or intramuscular injections ranging from 0. In the single case study of tacrine used to reverse delirium induced by anticholinergic med ication, 30 mg i. Consequently, one would expect such deliria to reverse at least to some extent with repletion of the deficient vita min. Although this has not been subjected to rigorous trials, there are some case reports and case series supporting this effect. A malnourished hemodialysis patient with nicotinamide deficiency had a paranoid delirium that responded to parenteral nicotinamide, 500 mg/day (100). In one randomized controlled trial (103), 26 elderly patients undergoing orthopedic surgery received treatment with intravenous vitamins B and C preoperatively and postoperatively and were compared to 32 age-matched surgical control subjects who did not receive vitamins. There was no difference between the intervention and control groups in the incidence of post operative confusion (39% versus 38%) or in the preoperative thiamine status as determined by serum assays. In general, any patient with delirium who has a reason to be B vitamin deficient. Morphine and paralysis Hypoxia, fatigue, and the metabolic consequences of overexertion all exacerbate delirium. Such hypercatabolic conditions are likely to accompany certain causes of agitated delirium. For such patients and for any cases of agitated delirium unresponsive to other pharmacologic inter ventions, the patient may require a paralytic agent and mechanical ventilation. Mor phine (or other opiate) is also an important palliative treatment in cases of delirium where pain is an aggravating factor (104). However, some opiates can exacerbate delirium, particularly through their metabolites, which possess anticholinergic activity (89). Although the treatment of delirium involves multiple modalities, certain components are essential and should be implemented with all pa tients. The goals of psychiatric management are similar for all patients with delirium and involve facilitating the identification and treatment of under lying etiologies, improving patient functioning and comfort, and ensuring the safety of patients and others. A) include coordinating care with other cli nicians; ensuring that the etiology is identified; ensuring that interventions for acute conditions are initiated; ensuring that disorder-specific treatments are provided; monitoring and ensuring Treatment of Patients With Delirium 27 Copyright 2010, American Psychiatric Association. The gen eral goals of environmental interventions are to remove factors that exacerbate delirium while providing familiarity and an optimal level of environmental stimulation; the general goals of supportive management include reorientation, reassurance, and education concerning delirium. These interventions are recommended for all patients with delirium, on the basis of some formal ev idence but mainly because of the value observed through clinical experience and the absence of adverse effects. Antipsychotic medications are the pharmacologic treatment of choice in most cases of delirium because of their efficacy in the treatment of psychotic symptoms. Haloperidol is most frequently used because of its short half-life, few or no anticholinergic side effects, no active metabolites, and lower likelihood of causing sedation. Haloperidol may be administered orally or intramuscularly, but it appears to cause fewer extrapyramidal side effects when admin istered intravenously. Titration to higher doses may be required for patients who continue to be agitated. Although total daily intravenous doses in the hundreds of milligrams have been given under closely monitored conditions, much lower doses usually suffice. Continuous intravenous infusions of antipsychotic medications can be used for patients who have required multiple bolus doses of antipsychotic medications. Droperidol, either alone or followed by haloperidol, can be considered for patients with delirium and acute agitation for whom a more rapid onset of action is required. The availability of new antipsychotic med ications (risperidone, olanzapine, and quetiapine) with their different side effect profiles has led some physicians to use these agents for the treatment of delirium. Benzodiazepines can exacerbate symptoms of delirium and, when used alone for general cases of delirium, have been shown to be ineffective. For these reasons, benzodiazepines as monotherapies are reserved for specific types of patients with delirium for which these medi cations may have particular advantages. For example, benzodiazepines are used most frequently to treat patients with delirium that has been caused by withdrawal of alcohol or benzodiaz epines. When a benzodiazepine is used, medications such as lorazepam, which are relatively short-acting and have no active metabolites, are preferable. Other somatic interventions have been suggested for patients with delirium who have par ticular clinical conditions or specific underlying etiologies; however, few data are available re garding the efficacy of these interventions in treating delirium. There is some suggestion that cholinergics such as physostigmine and tacrine may be useful in delirium caused by anticho linergic medications. For patients with delirium in whom pain is an ag gravating factor, palliative treatment with an opiate such as morphine is recommended. The presence or diagnosis of delirium does not in itself mean that a patient is incompetent or lacks capacity to give informed consent (128).

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