An open trial of olanzapine for the treatment of delirium in hospitalized cancer patients

Treating an established episode of delirium in palliative care: expert opinion and review of the current evidence base with recommendations for future development

CONTEXT

Delirium is a highly prevalent complication in patients in palliative care settings, especially in the end-of-life context.

OBJECTIVES

To review the current evidence base for treating episodes of delirium in palliative care settings and propose a framework for future development.

METHODS

We combined multidisciplinary input from delirium researchers and other purposely selected stakeholders at an international delirium study planning meeting. This was supplemented by a literature search of multiple databases and relevant reference lists to identify studies regarding therapeutic interventions for delirium.

RESULTS

The context of delirium management in palliative care is highly variable. The standard management of a delirium episode includes the investigation of precipitating and aggravating factors followed by symptomatic treatment with drug therapy. However, the intensity of this management depends on illness trajectory and goals of care in addition to the local availability of both investigative modalities and therapeutic interventions. Pharmacologically, haloperidol remains the practice standard by consensus for symptomatic control. Dosing schedules are derived from expert opinion and various clinical practice guidelines as evidence-based data from palliative care settings are limited. The commonly used pharmacologic interventions for delirium in this population warrant evaluation in clinical trials to examine dosing and titration regimens, different routes of administration, and safety and efficacy compared with placebo.

CONCLUSION

Delirium treatment is multidimensional and includes the identification of precipitating and aggravating factors. For symptomatic management, haloperidol remains the practice standard. Further high-quality collaborative research investigating the appropriate treatment of this complex syndrome is needed.

Delirium diagnostic and classification challenges in palliative care: subsyndromal delirium, comorbid delirium-dementia, and psychomotor subtypes

CONTEXT

Delirium often presents difficult diagnostic and classification challenges in palliative care settings.

OBJECTIVES

To review three major areas that create diagnostic and classification challenges in relation to delirium in palliative care: subsyndromal delirium (SSD), delirium in the context of comorbid dementia, and classification of psychomotor subtypes, and to identify knowledge gaps and research priorities in relation to these three areas of focus.

METHODS

We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant PubMed literature searches as the knowledge synthesis strategy in this review.

RESULTS

We identified six (SSD), 33 (dementia), and 44 (psychomotor subtypes) articles of relevance in relation to the focus of our review. Recent literature data highlight the frequency and impact of SSD, the relevance of comorbid dementia, and the propensity for a hypoactive presentation of delirium in the palliative population. The differential diagnoses to consider are wide and include pain, fatigue, mood disturbance, psychoactive medication effects, and other causes for altered consciousness.

CONCLUSION

Challenges in the diagnosis and classification of delirium in people with advanced disease are compounded by the generalized disturbance of central nervous system function that occurs in the seriously ill, often with comorbid illness, including dementia. Further research is needed to delineate the pathophysiological and clinical associations of these presentations and thus inform therapeutic strategies. The expanding aged population and growing focus on dementia care in palliative care highlight the need to conduct this research.

End-of-life delirium: issues regarding recognition, optimal management, and the role of sedation in the dying phase

CONTEXT

In end-of-life care, delirium is often not recognized and poses unique management challenges, especially in the case of refractory delirium in the terminal phase.

OBJECTIVES

To review delirium in the terminal phase context, specifically in relation to recognition issues; the decision-making processes and management strategies regarding its reversibility; the potential refractoriness of delirium to symptomatic treatment; and the role of sedation in refractory delirium.

METHODS

We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant electronic database literature searches (Ovid Medline, Embase, PsycINFO, and CINAHL) to inform this narrative review.

RESULTS

The overall management strategy for delirium at the end of life is directed by the patient's prognosis in association with the patient's goals of care. As symptoms of delirium are often refractory in the terminal phase, especially in the case of agitated delirium, the judicious use of palliative sedation is frequently required. However, there remains a lack of high-level evidence for the management of delirium in the terminal phase, including the role of antipsychotics and optimal sedation strategies. For the family and health-care staff, clear communication, education, and emotional support are vital components to assist with decision making and direct the treatment care plan.

CONCLUSION

Further research on the effectiveness of delirium management strategies in the terminal phase for patients and their families is required. Further validation of assessment tools for diagnostic screening and severity measurement is needed in this patient population.

Medically assisted hydration for adult palliative care patients

BACKGROUND

Many palliative care patients have reduced oral intake during their illness. The management of this can include the provision of medically assisted hydration with the aim of prolonging the life of a patient, improving their quality of life, or both. This is an updated version of the original Cochrane review published in Issue 2, 2008, and updated in February 2011.

OBJECTIVES

To determine the effect of medically assisted hydration in palliative care patients on their quality and length of life.

SEARCH METHODS

We identified studies by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, CANCERLIT, Caresearch, Dissertation abstracts, SCIENCE CITATION INDEX and the reference lists of all eligible studies, key textbooks and previous systematic reviews. The date of the latest search conducted on CENTRAL, MEDLINE and EMBASE was March 2014.

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs) or prospective controlled studies of medically assisted hydration in palliative care patients.

DATA COLLECTION AND ANALYSIS

We identified six relevant studies for this update. These included three RCTs (222 participants), and three prospective controlled trials (360 participants). Two review authors independently assessed the studies for quality and validity. The small number of studies and the heterogeneity of the data meant that a quantitative analysis was not possible, so we included a description of the main findings.

MAIN RESULTS

One study found that sedation and myoclonus (involuntary contractions of muscles) scores were improved more in the intervention group. Another study found that dehydration was significantly higher in the non-hydration group, but that some fluid retention symptoms (pleural effusion, peripheral oedema and ascites) were significantly higher in the hydration group. The other four studies (including the three RCTs) did not show significant differences in outcomes between the two groups. The only study that had survival as an outcome found no difference in survival between the hydration and control arms.

AUTHORS' CONCLUSIONS

Since the last version of this review, we found one new study. The studies published do not show a significant benefit in the use of medically assisted hydration in palliative care patients; however, there are insufficient good-quality studies to inform definitive recommendations for practice with regard to the use of medically assisted hydration in palliative care patients.

Comparison of symptoms of delirium across various motoric subtypes

AIM

The aim of this study was to determine the correlation between delirium motor subtypes and other symptoms of delirium.

METHODS

Three hundred and twenty-one (n = 321) consecutive patients referred to consultation-liaison psychiatry services were evaluated on Delirium Rating scale-Revised-98 version and amended Delirium Motor Symptom Scale.

RESULTS

Half of the patients had hyperactive subtype (n = 161; 50.15%) delirium. One-quarter of the study sample met the criteria for mixed subtype (n = 79; 24.61%), about one-fifth of the study sample met the criteria for hypoactive delirium subtype (n = 64; 19.93%), and only very few patients (n = 17; 5.29%) did not meet the required criteria for any of these three subtypes and were categorized as 'no subtype'. When the hyperactive and hypoactive subtypes were compared, significant differences were seen in the prevalence of perceptual disturbances, delusions, lability of affect, thought process abnormality, motor agitation and motor retardation. All the symptoms were more common in the hyperactive subtype except for thought process abnormality and motor retardation. Compared to hyperactive subtype, the mixed subtype had significantly higher prevalence of thought process abnormality and motor retardation. Significant differences emerged with regard to perceptual disturbances, delusions, lability of affect and motor agitation when comparing the patients with mixed subtype with those with hypoactive subtype. All these symptoms were found to be more common in the mixed subtype. No significant differences emerged for the cognitive symptoms as assessed on Delirium Rating scale-Revised-98 across the different motoric subtypes.

CONCLUSION

Different motoric subtypes of delirium differ on non-cognitive symptoms.

[Pharmacological treatment of delirium in palliative care patients. A systematic literature review]

This systematic literature review aims to collect and analyse relevant clinical trials for the drug treatment of delirium in palliative care. The search was conducted including July 2012 in Medline (from 1966) and Embase (from 1974). The search retrieved 448 studies, of which 3 studies could be included in the analysis. Treatment with the antipsychotic drug haloperidol can be recommended, which is also true to a somewhat lower extent for the antipsychotics olanzapine and aripiprazole. Treatment with lorazepam only should be avoided. This literature analysis reflects the positive clinical experience, especially when using haloperidol. To confirm these recommendations, further substantial clinical studies are needed.The English full-text version of this article can be found at SpringerLink (under "Supplemental").

First Spanish version of the Memorial Delirium Assessment Scale: psychometric properties, responsiveness, and factor loadings

CONTEXT

The Memorial Delirium Assessment Scale (MDAS) is a reliable and validated instrument with which to assess delirium. However, MDAS responsiveness has only been investigated in an indirect way. Also, neurobehavioral and global cognitive factors seem to be the MDAS main factor loads.

OBJECTIVES

The primary objective of this study was to evaluate MDAS responsiveness and analyze individual factors on this scale. The secondary objective was to confirm concurrent validity and reliability of the Spanish version of the MDAS.

METHODS

The translation-back translation method was used to obtain the Spanish version of the MDAS. Delirium diagnosis was determined by the clinical Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria and with the Confusion Assessment Method. Responsiveness and factor loadings were determined with the Delirium Rating Scale-Revised-98, the Mini-Mental State Examination (MMSE), and the MDAS at baseline (0 hours) and at 72 hours.

RESULTS

Variation in the scores of the Delirium Rating Scale-Revised-98 shows a correlation of r = 0.93, with variation in MDAS scores at P < 0.001. Variation in MMSE scores shows a correlation of r = -0.84, with variation in MDAS scores at P = 0.015. Factor I, neurobehavioral (reduced awareness, reduced attention, perceptual disturbance, delusions, altered psychomotor activity, and sleep-wake cycle disturbance), correlated moderately with the MMSE at -0.56. Factor II, global cognitive (disorientation, short-term memory impairment, impaired digit span, and disorganized thinking), correlated strongly with the MMSE at -0.81. Factor II was significantly more reliable than Factor I, rho = 0.7, P = 0.01.

CONCLUSION

The high responsiveness confirms the value of the MDAS for ongoing delirium assessment. Two differentiated factor loadings point to a potential future need for MDAS subscales.

What do we really know about the treatment of delirium with antipsychotics? Ten key issues for delirium pharmacotherapy

Despite the significant burden of delirium among hospitalized adults, no pharmacologic intervention is approved for delirium treatment. Antipsychotic agents are the best studied but there are uncertainties as to how these agents can be optimally applied in everyday practice. We searched Medline and PubMed databases for publications from 1980 to April 2012 to identify studies of delirium treatment with antipsychotic agents. Studies of primary prevention using pharmacotherapy were not included. We identified 28 prospective studies that met our inclusion criteria, of which 15 were comparison studies (11 randomized), 2 of which were placebo-controlled. The quality of comparison studies was assessed using the Jadad scale. The DRS (N = 12) and DRS-R98 (N = 9) were the most commonly used instruments for measuring responsiveness. These studies suggest that around 75% of delirious patients who receive short-term treatment with low-dose antipsychotics experience clinical response. Response rates appear quite consistent across different patient groups and treatment settings. Studies do not suggest significant differences in efficacy for haloperidol versus atypical agents, but report higher rates of extrapyramidal side effects with haloperidol. Comorbid dementia may be associated with reduced response rates but this requires further study. The available evidence does not indicate major differences in response rates between clinical subtypes of delirium. The extent to which therapeutic effects can be explained by alleviation of specific symptoms (e.g. sleep or behavioral disturbances) versus a syndromal effect that encompasses both cognitive and noncognitive symptoms of delirium is not known. Future research needs to explore the relationship between therapeutic effects and changes in pathophysiological markers of delirium. Less than half of reports were rated as reasonable quality evidence on the Jadad scale, highlighting the need for future studies of better quality design, and in particular incorporating placebo-controlled work.

Olanzapine for the prevention and treatment of chronic nausea and chemotherapy-induced nausea and vomiting

Olanzapine is an atypical antipsychotic agent of the thiobenzodiazepine class. It blocks multiple neurotransmitter receptors including dopaminergic at D1, D2, D3, D4 brain receptors, serotonergic at 5-HT2a, 5-HT2c, 5-HT3, 5-HT6 receptors, catecholamines at alpha1 adrenergic receptors, acetylcholine at muscarinic receptors, and histamine at H1 receptors. Olanzapine has five times the affinity for 5-HT2 receptors than D2 receptors and has been used to treat schizophrenia and delirium. Olanzapine's activity at multiple receptors, particularly at the D2, 5-HT2c, and 5-HT3 receptors which appear to be involved in nausea and emesis, has prompted its use in the treatment of nausea and vomiting refractory to standard antiemetics. Case reports and formal clinical trials have demonstrated its efficacy in the treatment of chronic nausea, the prevention of chemotherapy-induced nausea and emesis, and the treatment of breakthrough chemotherapy-induced nausea and emesis. Phase II and phase III clinical trials have demonstrated that there is a significant improvement in nausea when olanzapine is added to guideline directed prophylactic antiemetic agents 5-HT3 receptor antagonists and tachykinin NK1 receptor antagonists in patients receiving moderately or highly emetogenic chemotherapy Common side effects of olanzapine when used over a period of months include weight gain as well as an association with the onset of diabetes mellitus, but these effects have not been seen with short term use of daily doses of less than one week.

High-Dose Neuroleptics and Neuroleptic Rotation for Agitated Delirium Near the End of Life

Reason for the study:

Agitated delirium presents unique challenges for hospice and palliative care clinicians. Haloperidol, the recommended neuroleptic, may be ineffective at low dose, or poorly tolerated at higher doses.

Main Findings:

This article reports on two patients with refractory agitated delirium. Both developed extrapyramidal symptoms from haloperidol and required rotation to an alternate neuroleptic. Patient #1 received 2000 mg/day oral chlorpromazine. Patient #2 received greater than 200 mg/day sublingual olanzapine. Control of agitation was achieved, though the doses were substantially higher than has previously reported in the literature. Each patient experienced considerable sedation, though this was an acceptable side effect for the family. Each patient was transferred from the acute care hospital to a location of family preference. There they died within a week of transfer.

Conclusions:

Agitated delirium is a palliative care emergency. High doses of neuroleptic medications, with rotation to an alternate neuroleptic when side effects occur with standard haloperidol, may effectively palliate agitated delirium. This remedy can provide the patient with a peaceful dying in a place of their choosing.

Efficacy and safety of haloperidol versus atypical antipsychotic medications in the treatment of delirium

BACKGROUND

Most previous studies on the efficacy of antipsychotic medication for the treatment of delirium have reported that there is no significant difference between typical and atypical antipsychotic medications. It is known, however, that older age might be a predictor of poor response to antipsychotics in the treatment of delirium. The objective of this study was to compare the efficacy and safety of haloperidol versus three atypical antipsychotic medications (risperidone, olanzapine, and quetiapine) for the treatment of delirium with consideration of patient age.

METHODS

This study was a 6-day, prospective, comparative clinical observational study of haloperidol versus atypical antipsychotic medications (risperidone, olanzapine, and quetiapine) in patients with delirium at a tertiary level hospital. The subjects were referred to the consultation-liaison psychiatric service for management of delirium and were screened before enrollment in this study. A total of 80 subjects were assigned to receive either haloperidol (N = 23), risperidone (N = 21), olanzapine (N = 18), or quetiapine (N = 18). The efficacy was evaluated using the Korean version of the Delirium Rating Scale-Revised-98 (DRS-K) and the Korean version of the Mini Mental Status Examination (K-MMSE). The safety was evaluated by the Udvalg Kliniske Undersogelser side effect rating scale.

RESULTS

There were no significant differences in mean DRS-K severity or K-MMSE scores among the four groups at baseline. In all groups, the DRS-K severity score decreased and the K-MMSE score increased significantly over the study period. However, there were no significant differences in the improvement of DRS-K or K-MMSE scores among the four groups. Similarly, cognitive and non-cognitive subscale DRS-K scores decreased regardless of the treatment group. The treatment response rate was lower in patients over 75 years old than in patients under 75 years old. Particularly, the response rate to olanzapine was poorer in the older age group. Fifteen subjects experienced a few adverse events, but there were no significant differences in adverse event profiles among the four groups.

CONCLUSIONS

Haloperidol, risperidone, olanzapine, and quetiapine were equally efficacious and safe in the treatment of delirium. However, age is a factor that needs to be considered when making a choice of antipsychotic medication for the treatment of delirium.

TRIAL REGISTRATION

Clinical Research Information Service, Republic of Korea, (http://cris.nih.go.kr/cris/en/search/basic_search.jsp, Registered Trial No. KCT0000632).

[Perioperative care of palliative patients by the anesthetist : medical, psychosocial and ethical challenges]

Anesthetists will encounter palliative patients in the daily routine as palliative patients undergo operations and interventions as well, depending on the state of the disease. The first challenge for anesthetists will be to recognize the patient as being palliative. In the course of further treatment it will be necessary to address the specific problems of this patient group. Medical problems are optimized symptom control and the patient's pre-existing medication. In the psychosocial domain, good communication skills are expected of anesthetists, especially during the preoperative interview. Ethical conflicts exist with the decision-making process for surgery and the handling of perioperative do-not-resuscitate orders. This article addresses these areas of conflict and the aim is to enable anesthetists to provide the best possible perioperative care to this vulnerable patient group with the goal to maintain quality of life and keep postoperative recovery as short as possible.

Atypical antipsychotics in the treatment of delirium

The aim of this study was to review the efficacy and safety of atypical antipsychotics, comparing within class, placebo, or compared to another active treatment for delirium. A literature search was conducted using PubMed, EMBASE, and the Cochrane database (1 January 1990-5 November 2012). Selection criteria for review were prospective, controlled studies (comparison studies), using validated delirium rating scales as outcome measures. A total of six prospective, randomized controlled studies were included in the review. It was found that atypical antipsychotics are effective and safe in treating delirium, even though there seemed to be no difference between each agent. In particular, comparison studies with haloperidol showed that the efficacy of atypical antipsychotics was similar to that of low-dose haloperidol. It was concluded that atypical antipsychotics appear to be effective and tolerable in the management of delirium, even though the evidence is limited.

Altered mental status in older patients in the emergency department

Altered mental status is a common chief compliant among older patients in the emergency department (ED). Acute changes in mental status are more concerning and are usually secondary to delirium, stupor, and coma. Although stupor and coma are easily identifiable, the clinical presentation of delirium can be subtle and is often missed without actively screening for it. For patients with acute changes in mental status the ED evaluation should focus on searching for the underlying etiology. Infection is one of the most common precipitants of delirium, but multiple causes may exist concurrently.

Optimizing drug therapy in the surgical intensive care unit

This article provides a review of commonly prescribed medications in the surgical ICU, focusing on sedatives, antipsychotics, neuromuscular blocking agents, cardiovascular agents, anticoagulants, and antibiotics. A brief overview of pharmacology is followed by practical considerations to aid prescribers in selecting the best therapy within a given category of drugs to optimize patient outcomes.

Drug therapy for delirium in terminally ill adult patients

BACKGROUND

Delirium is a syndrome characterised by a disturbance of consciousness (often fluctuating), cognition and perception. In terminally ill patients it is one of the most common causes of admission to clinical care. Delirium may arise from any number of causes and treatment should be directed at addressing these causes rather than the symptom cluster. In cases where this is not possible, or treatment does not prove successful, the use of drug therapy to manage the symptoms may become necessary. This is an update of the review published on 'Drug therapy for delirium in terminally ill adult patients' in The Cochrane Library 2004, Issue 2 ( Jackson 2004).

OBJECTIVES

To evaluate the effectiveness of drug therapies to treat delirium in adult patients in the terminal phase of a disease.

SEARCH METHODS

We searched the following sources: CENTRAL (The Cochrane Library 2012, Issue 7), MEDLINE (1966 to 2012), EMBASE (1980 to 2012), CINAHL (1982 to 2012) and PSYCINFO (1990 to 2012).

SELECTION CRITERIA

Prospective trials with or without randomisation or blinding involving the use of drug therapies for the treatment of delirium in adult patients in the terminal phase of a disease.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality using standardised methods and extracted trial data. We collected outcomes related to efficacy and adverse effects.

MAIN RESULTS

One trial met the criteria for inclusion. In the 2012 update search we retrieved 3066 citations but identified no new trials. The included trial evaluated 30 hospitalised AIDS patients receiving one of three agents: chlorpromazine, haloperidol and lorazepam. The trial under-reported key methodological features. It found overall that patients in the chlorpromazine group and those in the haloperidol group had fewer symptoms of delirium at follow-up (to below the diagnostic threshold using the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and that both were equally effective (at two days mean difference (MD) 0.37; 95% confidence interval (CI) -4.58 to 5.32; between two and six days MD -0.21; 95% CI -5.35 to 4.93). Chlorpromazine and haloperidol were found to be no different in improving cognitive status in the short term (at 48 hours) but at subsequent follow-up cognitive status was reduced in those taking chlorpromazine. Improvements from baseline to day two for patients randomised to lorazepam were not apparent. All patients on lorazepam (n = 6) developed adverse effects, including oversedation and increased confusion, leading to trial drug discontinuation.

AUTHORS' CONCLUSIONS

There remains insufficient evidence to draw conclusions about the role of drug therapy in the treatment of delirium in terminally ill patients. Thus, practitioners should continue to follow current clinical guidelines. Further research is essential.

Delirium: underrecognized and undertreated

Delirium is a complex neuropsychiatric syndrome presenting primarily with disturbances of cognition, perception and sensorium, alertness, sleep/wake cycle, and psychomotor behavior in the context of a medical etiology. The presentation can be quite variable among patients and even within a given patient because of its waxing and waning course. This variability and overlap with other psychiatric syndromes has led to substantial underrecognition and undertreatment in clinical settings. Considering the significant morbidity and mortality associated with delirium and its tremendous economic burden, the failure to diagnose, refer, and treat such patients represents a critically important public health care issue. Clinicians should be systematically educated about delirium symptoms. Also, caregivers and family members of medically compromised patients should be educated about recognizing delirium. The use of structured diagnostic instruments and scales to follow the severity of symptoms has been an improvement in the field. However, much more research is needed into the use of such instruments and how they can be applied to clinical situations to improve the detection and treatment of delirium. Similarly, research is warranted that focuses on preventing delirium, potentially by identifying susceptible patients and intervening early. It is particularly challenging to devise cost-effective interventions for preventing and identifying delirium early in its course, given the rapid pace and resource limitations in inpatient and intensive care settings, and current data do not clearly indicate that such systems have proven benefit. Still, the indisputable health and financial costs of delirium indicate that prevention and identification should be a high priority.

Delirium in palliative medicine: a review

Delirium is a devastating complication of general medical and surgical populations but of particular importance in palliative medicine. It is a clinical syndrome that is often not recognized and, therefore, not treated appropriately. The presence of delirium is a predictor of increased morbidity and mortality, longer hospitalization, and more likely discharge to a nursing facility. This article reviews the pathophysiology, etiology, diagnosis, and treatment of delirium in the palliative medicine population.

Comprehensive approaches to managing delirium in patients with advanced cancer

Delirium is a frequently under-recognized complication in patients with advanced cancer. Uncontrolled delirium eventually leads to significant distress to patients and their families. However, delirium episodes can be reversed in half of these patients by eliminating precipitating factors and using appropriate interventions. The purpose of this narrative review is to discuss the most recent updates in the literature on the management of delirium in patients with advanced cancer. This article addresses the epidemiology, cause, pathophysiology, clinical characteristics, and assessment of delirium as well as various treatment options, including nonpharmacologic intervention and palliative sedation.

Olanzapine: palliative medicine update

Olanzapine is an atypical antipsychotic agent of the thienobenzodiazepine class. Olanzapine blocks multiple neurotransmitter receptors, including dopaminergic (D(1), D(2), D(3), and D(4)), serotonergic (5-hydroxytryptamine 2A [5-HT(2A)], 5-HT(2C), 5-HT(3), and 5-HT(6)), adrenergic (α(1)), histaminic (H(1)), and muscarinic (M(1), M(2), M(3), and M(4)) receptors. Olanzapine has a high affinity for the 5HT(2A) receptor, which is up to 5 times greater than the dopamine receptor, resulting in less propensity to the development of extrapyramidal side effects. The affinity of olanzapine for multiple receptors has lead to the identification of olanzapine as an important agent in the treatment of delirium, nausea, and vomiting. Olanzapine has been demonstrated to have opioid-sparing properties. Olanzapine is principally metabolized by glucuronidation, with a smaller metabolic contribution from the cytochrome oxidase system. Adverse effects of olanzapine include somnolence, postural hypotension, constipation, dizziness, restlessness, and weight gain. The purpose of this article is to outline the pharmacodynamics, pharmacology, and evidence for the use of olanzapine in palliative care.

Evidence-based treatment of delirium in patients with cancer

Delirium is the most common neuropsychiatric complication seen in patients with cancer, and it is associated with significant morbidity and mortality. Increased health care costs, prolonged hospital stays, and long-term cognitive decline are other well-recognized adverse outcomes of delirium. Improved recognition of delirium and early treatment are important in diminishing such morbidity. There has been an increasing number of studies published in the literature over the last 10 years regarding delirium treatment as well as prevention. Antipsychotics, cholinesterase inhibitors, and alpha-2 agonists are the three groups of medications that have been studied in randomized controlled trials in different patient populations. In patients with cancer, the evidence is most clearly supportive of short-term, low-dose use of antipsychotics for controlling the symptoms of delirium, with close monitoring for possible adverse effects, especially in older patients with multiple medical comorbidities. Nonpharmacologic interventions also appear to have a beneficial role in the treatment of patients with cancer who have or are at risk for delirium. This article presents evidence-based recommendations based on the results of pharmacologic and nonpharmacologic studies of the treatment and prevention of delirium.

A longitudinal study of motor subtypes in delirium: frequency and stability during episodes

OBJECTIVE

Motor-defined subtypes are a promising means of identifying clinically relevant patient subgroups but little is known about their course and stability during a delirium episode.

METHODS

We assessed 100 consecutive adult palliative care patients with DSM-IV delirium twice weekly during their episodes using the Delirium Motor Subtype Scale (DMSS), Delirium Rating Scale-Revised-98 (DRS-R98) and Cognitive Test for Delirium (CTD). DMSS subtypes were assigned for each assessment and analysed for stability within patients during episodes.

RESULTS

Across all assessments (n=303; mean 3 per patient, range 2-9), subtype occurrence was hypoactive (35%), mixed (26%), hyperactive (15%) and no subtype (24%). "No subtype" was associated with significantly lower DRS-R98 severity scores, of which 80% were subsyndromal, whereas mixed subtype assessments were the most impaired on the DRS-R98 and CTD. Subtypes were stable within delirium episodes in 62% of patients: 29% hypoactive, 18% mixed, 10% hyperactive and 6% no-subtype. The DRS-R98 noncognitive subscale scores differed across groups whereas cognitive subscale scores did not (p<0.001).

CONCLUSIONS

We conclude that motor subtypes occur in nearly all patients with full syndromal delirium and are often stable during an episode. Subtypes exhibited comparable levels of cognitive impairment but differed in non-cognitive symptoms, supporting the importance of cognitive testing to detect delirium in less overt cases.

[Informed Consent and the Approval by Ethics Committees of Studies Involving the Use of Atypical Antipsychotics in the Management of Delirium]

INTRODUCTION

Delirium is an acute alteration of consciousness and cognition. Atypical antipsychotics (AA) have recently become a main part of its treatment. Studies in this population generate a series of ethical dilemmas concerning the voluntary participation of patients and their state of vulnerability since their mental faculties are, by definition, compromised.

OBJECTIVE

To assess whether studies with AA for the treatment of delirium obtained an approval by an ethics committee on human research (ECHR), if an informed consent (IC) was obtained, whether the IC was verbal or written, and who gave the approval to participate.

METHOD

Systematic review of Medline for studies of delirium where quetiapine and olanzapine were the main treatment, assessing the existence of an ECHR approval and implementation of an IC.

RESULTS

11 studies were identified (6 of quetiapine and 5 of olanzapine). 5 had an ECHR approval.

CONCLUSIONS

Most studies examining the treatment of delirium with quetiapine or olanzapine were not subject to approval by an ECHR and most of them did not obtain an IC from the patient's legal guardian. It is essential that future studies of antipsychotics and other drugs for the treatment of delirium have the protocol approved by an ECHR and a written IC signed by the patient's legal representative, since by definition delirium is a condition that compromises superior mental processes.

Antipsychotics in the treatment of delirium in older hospitalized adults: a systematic review

OBJECTIVES

To examine evidence of the efficacy of antipsychotics in the treatment of delirium in older hospitalized adults.

DESIGN

Systematic literature review.

SETTING

Hospital.

PARTICIPANTS

Older adults with delirium.

MEASUREMENTS

The MEDLINE (January 1980-December 2010) and Cochrane Databases were searched using the keywords "delirium" and "antipsychotics." References of review articles were reviewed to identify additional studies. Study selection criteria included prospective design, more than 10 participants (in treatment arms), mean age 60 and older, standardized criteria for diagnosing delirium, and validated delirium rating scales for reporting outcomes.

RESULTS

Thirteen articles met selection criteria: six single-agent and seven comparison studies. Of these, eight (62%) had fewer than 25 participants in treatment arms, 10 (77%) recruited participants from psychiatry referrals, and eight (62%) did not clearly describe their screening methods. All single-agent studies were open-label studies. Of the comparison studies, five (71%) used randomization, but only one of these (a placebo-controlled study) used adequate allocation concealment methods, and only one other study (comparing two antipsychotics) described a double-blind method in detail. In the only placebo-controlled study (which was stopped early), no statistically significant differences in mean delirium severity scores were found at individual time points (Days 2, 3, 4, 7, 10). The other 12 studies reported improvements in delirium severity or resolution of delirium based on cutoff scores of the scales, but it is not clear from any of these studies what the natural course of delirium would have been without use of antipsychotics.

CONCLUSION

Because of severe methodological limitations, the studies in this review do not support the use of antipsychotics in the treatment of delirium in older hospitalized adults. Additional well-designed randomized placebo-controlled trials are needed.

A longitudinal study of motor subtypes in delirium: relationship with other phenomenology, etiology, medication exposure and prognosis

OBJECTIVE

Motor subtypes have promise as a means of identifying clinically relevant delirium subgroups. Little is known about their relationship to etiologies, medication exposure, and outcomes.

METHODS

Consecutive cases of DSM-IV delirium in palliative care patients were assessed twice-weekly throughout their delirium episodes using the Delirium Motor Subtype Scale (DMSS), Delirium Etiology Checklist (DEC) and Delirium Rating Scale Revised-98 (DRS-R98).

RESULTS

100 patients [mean age 70.2 ± 10.5] were assessed on 303 visits [range 2-9]. Over the entire episode, mean DRS-R98 Severity scores were 16.2 ± 5.7. The mean number of etiologies per case was 3.4 ± 1.2. Motor subtypes were no subtype throughout (6%), hypoactive subtype throughout (28%), mixed subtype throughout (18%), hyperactive subtype throughout (10%) and variable subtype (38%). DRS-R98 Total and Severity scales differed significantly across categories (highest in mixed) but only motor, sleep-wake cycle, perceptual and language disturbance items differed. The Generalized Estimating Equations (GEE) approach was used to explore the relationship between subtype profile and symptoms, medication exposure and etiology. This showed that apart from motor items, only delusions, affective lability, metabolic disturbance and CVA related to any subtype. Cross-sectional assessments indicated greater use of benzodiazepine and antipsychotics in hyperactive patients but GEE analyses did not identify major associations between motor subtype and medication exposure. Patients with sustained hypoactive subtype were significantly more likely to die within one month of study entry.

CONCLUSIONS

Motor profile in delirium is relatively consistent over episode course and relates more closely to delirium phenomenology than to etiology or medication exposure. Motor subtypes have comparable disturbance of key diagnostic features such as cognitive and thought process abnormalities. Although mixed subtype is the most phenomenologically intense, hypoactives have the poorest prognosis.

An open trial of aripiprazole for the treatment of delirium in hospitalized cancer patients

Objective:

The purpose of this study was to examine the efficacy and safety of aripiprazole in the treatment of delirium in hospitalized cancer patients, and to examine differential responses based on delirium subtypes.

Method:

We conducted an analysis of 21 hospitalized cancer patients at Memorial Sloan-Kettering Cancer Center (MSKCC) who had been evaluated and treated for delirium with aripiprazole, using an MSKCC Institutional Review Board (IRB) approved Clinical Delirium Database. Measures used were the Memorial Delirium Assessment Scale (MDAS), the Karnofsky Scale of Performance Status (KPS), and side effect rating at baseline (T1), 2–3 days (T2), and 4–7 days (T3). All measurements were integrated into the routine clinical care of patients. Doses of aripiprazole were adjusted based on clinical response.

Results:

Patients treated for delirium with aripiprazole experienced significant improvement and resolution of delirium, with MDAS scores declining from a mean of 18.0 at baseline (T1) to mean of 10.8 at T2 and a mean of 8.3 at T3. KPS scores improved from 28.1 at baseline (T1) to 35.2 at T2 and 41 at T3. Delirium resolved (based on MDAS < 10) in 52.4% of cases at T2 and in 76.2% at T3. The mean dosage of aripiprazole required was 18.3 mg (range of 5–30) daily at T3. In our cohort of patients with hypoactive delirium, we observed a delirium resolution rate of 100% compared to the cohort of patients with hyperactive delirium (58.3% rate of delirium resolution). MDAS scores improved from 15.6 at T1 to 5.7 at T3 in hypoactive delirium and from 19.9 at T1 to 10.2 at T3 in hyperactive delirium. In patients with pre-morbid cognitive deficits and the hyperactive subtype of delirium, we observed a more limited treatment response to aripiprazole treatment for delirium. There were no clinically significant side effects noted.

Significance of results:

Aripiprazole is effective and safe in the treatment of delirium in hospitalized cancer patients. These preliminary finding suggest that aripiprazole may be most effective in resolving delirium of the hypoactive subtype.

Blonanserin in the treatment of delirium

The purpose of the present study was to provide preliminary data on the usefulness and safety of blonanserin for patients with delirium in the intensive care unit (ICU). The charts of 32 consecutive patients with delirium in the ICU were retrospectively reviewed. These patients were treated with blonanserin. A total of 96.6% had reduction in Memorial Delirium Assessment Scale score. The proportion of patients with side-effects was 24.1%. Blonanserin may be effective and safe in the treatment of delirium in the ICU.

Depression and end-of-life care for patients with cancer

Patients with cancer and depression experience more physical symptoms, have poorer quality of life, and are more likely to have suicidal thoughts or a desire for hastened death than are cancer patients who are not depressed. Despite the ubiquity of depressive symptoms in cancer patients at the end of life, critical questions remain unanswered with respect to etiopathogenesis, diagnosis, and treatment of depression in these vulnerable patients. The pharmacotherapy of depression in patients with advanced cancer should be guided by a palliative care approach focused on symptom reduction, irrespective of whether the patient meets diagnostic criteria for major depression. Earlier and more intensive supportive care for patients with cancer reduces symptom burden and may prolong life for patients with advanced disease. Symptom-oriented clinical trials are needed to improve end-of-life cancer care.

The evaluation and management of delirium among older persons

This article reviews the pathophysiology, prevalence, incidence, and consequences of delirium, focusing on the evaluation of delirium, the published models of care for prevention in patients at risk of delirium, and management of patients for whom delirium is not preventable. Evidence on why physical restraints should not be used for patients with delirium is reviewed. Current available evidence on antipyschotics does not support the role for the general use in the treatment of delirium. An example of a restraint-free, nonpharmacologic management approach [called the TADA approach (tolerate, anticipate, and don't agitate)] is presented.

Atypical Antipsychotics for the Treatment of ICU Delirium

Delirium is commonly described in critically ill patients as 1 factor contributing to increased length of intensive care unit and hospital stay, secondary complications, and increased mortality. Initial screening tools for delirium in hospitalized patients are generally easy to use; however, many centers have struggled with implementing these tools in a consistent and systematic manner. Haloperidol has traditionally been prescribed as the primary agent of choice for the treatment of delirium in critically ill patients. Clinicians have been challenged to consider alternative agents due to adverse effects such as extrapyramidal symptoms, QTc prolongation, and possible torsades de pointes with haloperidol use. The atypical antipsychotics are attractive alternatives to haloperidol with improved safety profiles but are flawed by limited data to support dosing and efficacy in this patient population. Future studies that provide large, prospective, double-blinded, placebo-controlled data to support the implementation of these agents as standard therapy over haloperidol are needed.

Antipsychotics for the prevention and treatment of delirium in the intensive care unit: what is their role?

Delirium affects up to 80% of critically ill patients, worsens outcomes, and is frequently treated with antipsychotics despite uncertainty regarding their efficacy and safety. We identified published, English-language, randomized, controlled studies evaluating antipsychotics in ICU patients either with delirium or at risk for developing delirium. In 105 mechanically ventilated patients, the number of days spent alive without delirium or coma was similar between haloperidol (median, 14.0 days; interquartile range [IQR], 6.0-18.0 days) or ziprasidone (median, 15.0 days; IQR, 9.1-18.0 days) prophylaxis, and placebo (median, 12.5 days; IQR, 1.2-17.2 days) groups (p=0.66). Treating delirium with quetiapine, compared to placebo, in 36 ICU patients was associated with a quicker resolution of delirium (median for quetiapine, 1.0 days; IQR, 0.5-3.0 days/median for placebo, 4.5 days; IQR, 2.0-7.0 days [p=0.001]). In a third study, a similar decrease over time in delirium severity was noted between fixed-dose oral olanzapine and oral haloperidol in patients with delirium. None of the studies identified serious safety concerns with administering the antipsychotics that were studied. Published prospective, randomized clinical trials evaluating antipsychotic therapy for preventing or treating delirium in the ICU are few in number. The conclusions that can be drawn from them are limited by their heterogeneity, inconsistency in incorporating non-antipsychotic strategies known to reduce delirium or in maintaining patients in an arousable state, their size, the lack of ICU and non-ICU clinical outcomes evaluated, and the lack of placebo arms. A research framework for future evaluation of the use of antipsychotic therapy in the critically ill is proposed.

Evidence-based approaches to other symptoms in advanced cancer

Dyspnea, nausea and vomiting, anorexia, fatigue, and sleep disturbances are common and distressing in advanced cancer. We updated previous systematic reviews of how these symptoms can be alleviated with targeted literature searches. The approach to these symptoms requires comprehensive symptom assessment; treating underlying causes when benefits exceed risks; prioritizing treatment, as patients usually have many symptoms; and addressing psychosocial and spiritual distress. For dyspnea, evidence supports systemic opioids and nonpharmacological treatments such as a fan. The strongest evidence supports metoclopramide for cancer-related nausea and octreotide for bowel obstruction. For anorexia, enteral or parenteral nutrition is indicated with obstruction and expected prognosis of at least 6 weeks. Evidence supports several drugs for appetite affecting quality of life. For fatigue, evidence supports psychosocial interventions and methylphenidate. For insomnia, evidence supports cognitive-behavioral therapy in cancer; no sleep agents have superior effectiveness.

Subcutaneous olanzapine for hyperactive or mixed delirium in patients with advanced cancer: a preliminary study

CONTEXT

Oral olanzapine is effective in controlling agitation in patients with delirium, but often, parenteral administration is necessary. Intramuscular (IM) olanzapine is approved for managing agitation in schizophrenia, but this route is inappropriate for terminally ill patients.

OBJECTIVES

The purpose of this pilot study was to determine the safety and tolerability of subcutaneous (SC) olanzapine in the management of hyperactive or mixed delirium in patients with advanced cancer.

METHODS

We conducted a prospective open-label study in patients with advanced cancer who had agitated delirium (Richmond Agitation Sedation Scale [RASS] score ≥+1) that had not responded to a 10mg or higher dose of parenteral haloperidol over 24 hours. Patients received olanzapine 5mg SC every eight hours for three days and continued haloperidol for breakthrough agitation. For patients requiring more than 8mg of rescue haloperidol daily, the olanzapine dose was increased to 10mg SC every eight hours. Injection site, systemic toxicity, and efficacy (RASS score <+1 and total haloperidol dose <8mg per 24 hours on the last study day) were evaluated.

RESULTS

Twenty-four patients received at least one olanzapine injection, and 15 (63%) completed the study. Median age of evaluable patients was 58 years (range 49-79), and 67% were males. No injection site toxicity was observed after 167 injections. Probable systemic toxic effects were observed in four patients (severe hypotension [blood pressure <90/50mmHg], paradoxical agitation, diabetes insipidus, and seizure). Efficacy was achieved in nine (37.5%) patients.

CONCLUSIONS

IM olanzapine is well tolerated subcutaneously. Further research is needed to evaluate its efficacy in controlling agitated delirium.

Delirium in the older emergency department patient: a quiet epidemic

Delirium is defined as an acute change in cognition that cannot be better accounted for by a preexisting or evolving dementia. This form of organ dysfunction commonly occurs in older patients in the emergency department (ED) and is associated with a multitude of adverse patient outcomes. Consequently, delirium should be routinely screened for in older ED patients. Once delirium is diagnosed, the ED evaluation should focus on searching for the underlying cause. Infection is one of the most common precipitants of delirium, but multiple causes may exist concurrently.

Impact of an educational workshop upon attitudes towards pharmacotherapy for delirium

BACKGROUND

There is uncertainty regarding the optimal use of pharmacological strategies in delirium particularly regarding preferred agents, duration of treatment and effectiveness in different populations.

METHODS

Attitudes towards delirium pharmacotherapy were investigated before and after an educational workshop using the format of a television game show.

RESULTS

Most respondents (65/66) reported psychotropic use with variable frequency (median 60%). Antipsychotic use was inversely related to perception of supporting evidence (p = 0.02). Respondents rated sedative (38%) and antipsychotic (33%) effects as the principal mechanism of action rather than a specific neurochemical anti-delirium effect (21%). Haloperidol was the preferred first-line agent (65%). Suggested continuation treatment after symptom resolution was three days. Eleven respondents had used psychotropics prophylactically. Antipsychotic use was influenced by concerns regarding potential for extrapyramidal (52%), sedative (32%), cerebrovascular (30%) and metabolic (8%) effects. Post-workshop concerns regarding extrapyramidal effects were reduced with a more positive general attitude towards pharmacological interventions, especially in hypoactive presentations (61%) and prophylactically in high-risk patients (56%).

CONCLUSIONS

Attitudes towards key aspects of delirium pharmacotherapy vary considerably and relate to concerns regarding side effect potential more than perceived mechanism of action. Educational interventions can impact positively upon attitudes.

Validating a new clinical subtyping scheme for delirium with electronic motion analysis

The usefulness of motor subtypes of delirium is unclear due to inconsistency in sub-typing methods and a lack of validation with objective measures of activity. The activity of 40 patients was measured with 24 h accelerometry monitoring. Patients with Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) delirium (n=30) were allocated into hyperactive, hypoactive and mixed motor subtypes. Delirium subtypes differed in relation to overall amount of activity, including movement in both sagittal and transverse planes. Differences were greater in the daytime and during the early evening 'sundowning' period. Frequency of postural changes was the most discriminating measure examined. Clinical subtypes of delirium defined by observed motor behaviour on the ward differ in electronically measured activity levels.

Delirium associated with olanzapine therapy in an elderly male with bipolar affective disorder

Atypical antipsychotic medications are commonly used to treat symptoms of delirium. Olanzapine has been successfully used in the treatment of delirium. However, there have been few case reports of delirium associated with olanzapine. We hereby report a case of delirium associated with olanzapine therapy. Possible risk factors and underlying pathogenesis is discussed.

Risperidone versus olanzapine for the treatment of delirium

OBJECTIVE

This study compared the effectiveness of risperidone and olanzapine in the treatment of delirium.

METHODS

This was a 7-day, randomized, comparative clinical trial of risperidone and olanzapine in patients with delirium. The primary outcome measure was the Delirium Rating Scale-Revised-98 (DRS-R-98).

RESULTS

We enrolled 32 subjects (median age, 70 years). Significant within-group improvements in the DRS-R-98 scores over time were observed at every time point in both treatment groups; however, differences in the change of the DRS-R-98 score from baseline were not significant between the treatment groups. On the first day after drug treatment, there was a trend toward greater improvement in the DRS-R-98 score in the olanzapine group compared with the risperidone group, but it did not reach statistical significance (p = 0.076). The response rates did not differ significantly between the two groups (risperidone group: 64.7%, olanzapine group: 73.3%). However, the response to risperidone was significantly poorer in patients >or=70 years of age compared with those aged <70 years. There was no significant difference in the safety profiles, including extrapyramidal symptoms (EPSs), between the two groups.

CONCLUSION

Risperidone and olanzapine were equally effective in reducing delirium symptoms. The response to risperidone was poorer in the older age group.

Factors associated with prolonged delirium: a systematic review

BACKGROUND

Delirium frequently accompanies acute illness. With treatment of the illness, some individuals recover from delirium while for others the symptoms persist. It is not understood why some individuals improve but others do not. The purpose of this paper is to review systematically what is known about the factors associated with the persistence of delirium.

METHODS

A medical literature search was conducted using several bibliographic databases, supplemented by manual searches of the references. English or French studies were included if they compared two groups of delirious individuals in delirium duration or persistence up to six months after the onset of delirium, diagnosed prospectively with the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria (or a scale derived and validated against the DSM). Information was collected on the association between possible non-therapeutic prognostic variables and delirium persistence.

RESULTS

Twenty-one observational studies were included, in various settings (e.g. mixed medical-surgical, medical or geriatric, surgical, psychiatric, cancer or palliative care units). Variables assessed included patient characteristics (e.g. age, dementia, medical comorbidity, functional status), delirium characteristics (e.g. presence of hypoactive symptoms, delirium severity) and illness characteristics (e.g. severity of illness, and underlying acute illness). Overall, studies suggested that delirium is often persistent at discharge or beyond. Persistence was associated with dementia, increasing numbers of medical conditions, increasing severity of delirium, hypoactive symptoms and hypoxic illnesses.

CONCLUSIONS

Preliminary findings suggest that some factors may identify those at risk for persistent delirium; however, more research is needed.

Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study

OBJECTIVE

To compare the efficacy and safety of scheduled quetiapine to placebo for the treatment of delirium in critically ill patients requiring as-needed haloperidol.

DESIGN

Prospective, randomized, double-blind, placebo-controlled study.

SETTING

Three academic medical centers.

PATIENTS

Thirty-six adult intensive care unit patients with delirium (Intensive Care Delirium Screening Checklist score > or = 4), tolerating enteral nutrition, and without a complicating neurologic condition.

INTERVENTIONS

Patients were randomized to receive quetiapine 50 mg every 12 hrs or placebo. Quetiapine was increased every 24 hrs (50 to 100 to 150 to 200 mg every 12 hrs) if more than one dose of haloperidol was given in the previous 24 hrs. Study drug was continued until the intensive care unit team discontinued it because of delirium resolution, therapy > or = 10 days, or intensive care unit discharge.

MEASUREMENTS AND MAIN RESULTS

Baseline characteristics were similar between the quetiapine (n = 18) and placebo (n = 18) groups. Quetiapine was associated with a shorter time to first resolution of delirium [1.0 (interquartile range [IQR], 0.5-3.0) vs. 4.5 days (IQR, 2.0-7.0; p =.001)], a reduced duration of delirium [36 (IQR, 12-87) vs. 120 hrs (IQR, 60-195; p =.006)], and less agitation (Sedation-Agitation Scale score > or = 5) [6 (IQR, 0-38) vs. 36 hrs (IQR, 11-66; p =.02)]. Whereas mortality (11% quetiapine vs. 17%) and intensive care unit length of stay (16 quetiapine vs. 16 days) were similar, subjects treated with quetiapine were more likely to be discharged home or to rehabilitation (89% quetiapine vs. 56%; p =.06). Subjects treated with quetiapine required fewer days of as-needed haloperidol [3 [(IQR, 2-4)] vs. 4 days (IQR, 3-8; p = .05)]. Whereas the incidence of QTc prolongation and extrapyramidal symptoms was similar between groups, more somnolence was observed with quetiapine (22% vs. 11%; p = .66).

CONCLUSIONS

Quetiapine added to as-needed haloperidol results in faster delirium resolution, less agitation, and a greater rate of transfer to home or rehabilitation. Future studies should evaluate the effect of quetiapine on mortality, resource utilization, post-intensive care unit cognition, and dependency after discharge in a broader group of patients.