• Journal of Hospice and Palliative Care
• /
• v.19 no.3
• /
• pp.201-210
• /
• 2016

Delirium is a common symptom in patients with terminal cancer. The prevalence increases in the dying phase. Delirium causes negative effects on quality of life for both patients and their families, and is associated with higher mortality. However, some studies reported that it tends to remain unrecognized in palliative care setting. That may be related with difficulties to distinguish the symptom from others with overlapping characteristics such as depression and dementia, and a lack of knowledge regarding assessment and diagnostic tools. We suggest that accurate recognition with validated tools and early diagnosis of the symptom should be highly prioritized in delirium management in palliative care setting. After diagnosing delirium, it is important to identify and address reversible precipitants such as medication, dehydration, and infection. Non-pharmacological interventions including comfortable environment for the patient and family education are also essential in the management strategy. If such interventions prove ineffective or insufficient to control hyperactive symptoms, pharmacologic interventions with antipsychotics and benzodiazepine can be considered. Until now, low levels of haloperidol remains the standard treatment despite a lack of evidence. Atypical antipsychotics such as olanzapine, quetiapine and risperidone reportedly have similar efficacy with a stronger sedating property and less adverse effect compared to haloperidol. Currently, delirium medications that can be used in palliative care setting require more clinical trials, and thus, clinical guidelines are not sufficiently available. We suggest that it is warranted to develop clinical guidelines based on well-designed clinical studies for palliative care patients.

• Journal of Hospice and Palliative Care
• /
• v.13 no.4
• /
• pp.252-256
• /
• 2010

Breathlessness is a frequent and distressing symptom in terminal cancer patients. Refractory breathlessness is defined as a state that does not respond to conventional disease-specific therapy with an exclusion of reversible underlying causes, and the main classes of symptomatic drug treatments include opioids and benzodiazepines. Korean Family Medicine Palliative Medicine Research Group discussed two terminal cancer patients in whom severe breathlessness with different causes were treated with inhalation of nebulized furosemide, which is an emerging option of palliative treatment. It still remains unclear how it becomes effective or how much it is effective, therefore, its routine use seems to be somewhat early. Nevertherless, if a patient with intractable breathlessness does not have a marked obstructive airway lesion, its use should be considered. Based on the discussion in the seminar, we want to share our experience of the application of inhaled furosemide with other palliative care practitioners and strongly recommend further research on this topic in the future.

• Korean Journal of Psychosomatic Medicine
• /
• v.27 no.2
• /
• pp.111-118
• /
• 2019

Objectives : The purpose of this study was to investigate the clinical characteristics of antipsychotic medication prescription for the symptom control in patients with delirium. Methods : One hundred and eighty-five patients referred to consultation-liaison psychiatric services for delirium due to general medical condition were included in this study. All subjects were divided into two groups (antipsychotics users vs. antipsychotics nonusers), and comparison analyses on their clinical characteristics were performed. Results : One hundred and twenty nine patients (66.5%) used antipsychotics for their delirium, and 56 patients (30.3%) did not use antipsychotics. The history of psychotropic medication was more frequently observed in antipsychotic users (5.4% vs. 18.6%, χ²=5.498, p=0.022). Especially, the history of benzodiazepine use was significantly high in antipsychotics users. The total score and sub-items of delirium rating scale-severity items except for the psychomotor retardation item showed higher scores in antipsychotic users than in nonusers (all p<0.05). The total score of the delirium rating scale-diagnosis items was higher in antipsychotic users than in the nonusers (p=0.010). Conclusions : Delirium patients with more severe delirium symptoms and with more history of benzodiazepine use were treated with antipsychotics more frequently than those without. These findings imply that benzodiazepine may not only exacerbate delirium but be associated with aggression or psychomotor agitation that need immediate intervention. Clinicians may need to pay attention not only these external symptoms but also to hypoactive symptoms that may lead to misdiagnosis and undertreatment.

• The Korean Journal of Nuclear Medicine Technology
• /
• v.12 no.3
• /
• pp.176-180
• /
• 2008

Department of Nuclear Medicine in Seoul National University Hospital (SNUH) had developed $^{18}F$-Flumazenil as Benzodiazepine receptor imaging agent for PET diagnosis of Epilepsy. But production Activity of $^{18}F$-Flumazenil is decreased owing to this method has difficult synthesis procedures and pretty long synthesis time. In this study, we can modify synthesizing method to have more simple procedure and less spend time and help to increase production Activity. Old method: Radioactivity was produced by cyclotron was captured by QMA cartridge that was activated. Captured radioactivity was eluted into the reaction vial by using kryptofix solution and delivered. After evaporation of eluent, the azeotrophic drying step repeated two times. tosylflumazenil in anhydrous Acetonitrile was added to a reaction vial while bubbling. The reaction mixture was evaporated until the mixture volume was 0.5 mL. Reaction vial washed with 20 % Acetonitrile and that solution went into the reaction vial. The reaction mixture was loaded to the HPLC loop by hand and purified $^{18}F$-Flumazenil by HPLC column. New method: We used $TBAHCO_3$ solution as a eluent. After the eluent was evaporated, tosylflumazenil in anhydrous acetonitrile was added to a reaction vial and the reaction mixture was bubbled for 15 minutes. It was evaporated until the mixture volume became 0.5 mL. It was loaded to the HPLC loop. In old method, $^{18}F$-Flumazenil was synthesized via 6 steps synthesis procedures in 105 minutes with 30~35% synthesizing yield (non-decay correction) and specific activity was about $0.5{\sim}2{\times}10^5$ Ci/mole. In new method, It had 3 steps synthesis procedures in 53 minutes with 40~45% synthesizing yield and specific activity was about $3{\sim}8{\times}10^5$ Ci/mole. This method leads to improve of minimizing synthesis time, increasing synthesis yield and specific activity. While we can load reaction mixture to the HPLC loop, we can expose high radiation field thanks to used by hand.

• Korean Journal of Psychosomatic Medicine
• /
• v.16 no.2
• /
• pp.69-74
• /
• 2008

Delirium is an organic psychiatric syndrome characterized by an acute onset, prominent disturbance of consciousness and cognitive impairment with fluctuating course. Although there is not a clear consensus concerning the optimal classification system for delirium subtypes, Lipowski(1983) firstly classified delirium by psychomotor activity, namely hyperactive, hypoactive, and mixed. According results of several following studies, prevalence of hypoactive delirium were not less than that of hyperactive delirium. But a diagnosis of hypoactive delirium often missed, which is most frequently misdiagnosed as depression and dementia. Hyperactive delirium can be caused by alcohol or benzodiazepine withdrawal, would be related with excessive dopamine and cholinergic deficiency, and is more responsive to high-potency antipsychotics therapy. Hypoactive delirium would be caused by metabolic encephalopathy, and tends to present a less responsiveness to antipsychotics and poorer overall prognosis with a prolonged duration of admission than hyperactive delirium. Delirium is not a homogenous syndrome. Because of different subtypes, it may have dissimilar underlying pathogenetic pathways. So different treatment strategies between various subtypes may be needed.

• YAKHAK HOEJI
• /
• v.36 no.5
• /
• pp.496-505
• /
• 1992

The correlation between GABA receptors($GABA_A$ and $GABA_B$ receptor) and benzodiazepine receptor on the saline infusion-induced micturition reflex contraction was studied in the female rat. To investigate the effect of ${\gamma}-aminobutyric$ acid(GABA) on the micturition reflex, exogenous GABA(10 mg/kg) and GABA transaminase inhibitor(aminooxyacetic acid; AOAA $1\;{\mu}g$) were administered intravenously(i.v.) and intracerebroventriculary(i.c.v.), respectively. In result, both GABA and AOAA inhibited the saline induced micturition reflex contraction. This AOAA induced inhibition of micturition reflex was blocked by both bicuculine. $GABA_A$ receptor antagonist, and Ro 15-1788, benzodiazepine receptor antagonist. Muscimol, $GABA_A$ receptor antagonist($0.1\;{\mu}g$ i.c.v., $3\;{\mu}g$ intrathecal; i.t., 1 mg/kg i.v.) and baclofen, $GABA_A$ receptor agonist($1\;{\mu}g$ i.c.v., $3\;{\mu}g$ i.t., 1 mg/kg i.v.) also inhibited the bladder contraction. Pretreatment of bicuculline($1\;{\mu}g$ i.c.v.), but not of 5-aminovaleric acid(AVA, $1\;{\mu}g$ i.c.v.), $GABA_B$ receptor antagonist blocked the central inhibition of muscimol. These inhibitory effects were reversed by Ro15-1788 but were potentiated by flurazepam, benzodiazepine receptor antagonist. On the other hand, the inhibitory effects of baclofen were not affected by Ro 15-1788. Diazepam and flurazepam also inhibited the micturition reflex contraction when they were administered $3\;{\mu}g$ i.c.v., $10\;{\mu}g$ i.t., $10\;{\mu}M$, $30\;{\mu}M$ transurethrally, respectively. In conclusion, these results suggest that the micturition reflex is mediated by $GABA_A$, $GABA_B$ receptor and benzodiazepine receptor. The bezodiazepines increase the receptor binding of GABA to the $GABA_A$ receptor, so that the benzodiiazepines show the synergistic effect on the inhibition of the micturition reflex contraction, but not to the $GABA_B$ receptor.

• Korean Journal of Psychosomatic Medicine
• /
• v.31 no.2
• /
• pp.63-71
• /
• 2023

Urinary incontinence (UI), affecting 3%-11% of males and 25%-45% of females globally, is expected to rise with an aging population. It significantly impacts mental health, causing depression, stress, and reduced quality of life. UI can exacerbate psychiatric conditions, affecting treatment compliance and effectiveness. It is categorized into transient and chronic types. Transient UI, often reversible, is caused by factors summarized in the acronym DIAPPERS: Delirium, Infection, Atrophic urethritis/vaginitis, Psychological disorders, Pharmaceuticals, Excess urine output, Restricted mobility, Stool impaction. Chronic UI includes stress, urge, mixed, overflow, functional, and persistent incontinence. Drug-induced UI, a transient form, is frequently seen in psychiatric treatment. Antipsychotics, antidepressants, and other psychiatric medications can cause UI through various mechanisms like affecting bladder muscle tone, altering nerve reflexes, and inducing other conditions like diabetes or epilepsy. Specific drugs like lithium and valproic acid have also been linked to UI, though mechanisms are not always clear. Managing UI in psychiatric patients requires careful monitoring of urinary symptoms and judicious medication management. If a drug is identified as the cause, options include discontinuing, reducing, or adjusting the dosage. In cases where medication continuation is necessary, additional treatments like desmopressin, oxybutynin, trihexyphenidyl, or amitriptyline may be considered.