Delirium, opioid regulation, and pathological gambling

doi:10.1136/bmj.39206.656447.3A

BMJ 2007;334 (21 April), doi:10.1136/bmj.39206.656447.3A

Editor's Choice

US editor's choice

Delirium, opioid regulation, and pathological gambling

Douglas Kamerow, US editor

dkamerow{at}bmj.com

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

Even in our hi-tech world, the diagnosis of delirium remainsa clinical one. Medical history is crucial—has there beena recent decline in cognitive function? Fluctuating awareness,impairment of memory, and disorganized thinking are commonlyseen. Precipitants may include infections, drugs, surgery, ormyocardial infarction.

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

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

Finally, Sui Wong and Malcolm Steiger describe an importantside effect of Parkinson's disease (or its treatment)—pathologicalgambling (doi: 10.1136/bmj.39176.363958.80). Up to 7% of Parkinson'spatients have this problem, which is more common if the patientis taking dopamine agonists. Easy access to internet gamblinghas 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 patientsand their families about changes in behavior and developmentof any new compulsions in order to identify the problem early.

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