Delirium, opioid regulation, and pathological gambling

Delirium is common in elderly patients in emergency and inpatient settings. It is often caused by hospitalization and its attendant procedures. John Young and Sharon Inouye review the causes, diagnosis, and treatment of delirium, and distinguish it from dementia (doi: 10.1136/bmj.39169.706574.AD).

Even in our hi-tech world, the diagnosis of delirium remains a clinical one. Medical history is crucial—has there been a recent decline in cognitive function? Fluctuating awareness, impairment of memory, and disorganized thinking are commonly seen. Precipitants may include infections, drugs, surgery, or myocardial infarction.

Differentiating delirium and dementia is often difficult. They are probably related both clinically and pathophysiologically. While the key is obtaining a history of the patient's clinical course from a family member or caregiver, in most cases it makes sense to consider all older people presenting with confusion to have delirium until proven otherwise.

Another difficult problem for doctors can be the proper prescription of opiates for pain relief. Jane Ballantyne describes the history of regulation and over-regulation of opioid prescribing in the United States (doi: 10.1136/bmj.39175.458275.BE). Recent rulings and counter-rulings by the US Drug Enforcement Agency have left doctors unsure what is legal and what isn't. Many patients with acute pain due to terminal diseases are receiving appropriate, helpful doses of opiates. Some, however, are not. High profile cases of over-prescription and drug addiction have led to tightened regulations. This hurts patients with real pain problems, as doctors are often caught in the middle.

Finally, Sui Wong and Malcolm Steiger describe an important side effect of Parkinson's disease (or its treatment)—pathological gambling (doi: 10.1136/bmj.39176.363958.80). Up to 7% of Parkinson's patients have this problem, which is more common if the patient is taking dopamine agonists. Easy access to internet gambling has brought temptation into the homes of vulnerable patients. They may run up substantial debts before the problem is recognized. The authors recommend routine questioning of Parkinson's patients and their families about changes in behavior and development of any new compulsions in order to identify the problem early.