Multidisciplinary Team Interventions for the management of delirium in hospitalized patients

Prognosis of delirium in hospitalized elderly: worse than we thought

BACKGROUND

Despite treatment of the associated condition, delirious persons do not always recover for unknown reasons. We sought to determine early prognostic indicators of poor recovery following an episode of delirium in older medical in-patients.

METHODS

Between October 2009 and July 2011, consecutively admitted older (≥70 years old) medical in-patients at the London Health Sciences Centre (Ontario) were screened for delirium. Delirious patients were followed. The primary outcome was poor recovery, in delirious patients, defined by death, long-term institutionalization, or functional decline (decreased activities of daily living), at discharge or 3 months after discharge, elicited from the medical chart or post-discharge caregiver telephone interviews.

RESULTS

One thousand two hundred thirty-five in-patients (mean age 82.6 years, 42% men) were screened, delirium occurred in 355 (29%). Follow-up data was known on 342 (96%), and 237 (69%) had poor recovery: 55 died (54 in hospital and one after discharge), 136 were permanently institutionalized (86 directly from hospital and 50 after discharge), and 46 had functional decline (at a median of 103 days after discharge). Poor recovery was associated in the derivation sample with advanced age, lower baseline function, hypoxia, higher delirium severity scores, and acute renal failure; this was predictive of poor recovery in the validation sample (receiver operating characteristic area 0.68, 95% confidence interval: 0.57-0.79); however, even individuals with "low" risk had high (50%) poor recovery rates.

INTERPRETATION

Poor recovery after delirium is common and associated with certain characteristics. However, even "lower risk" delirious individuals do poorly. More research is needed to understand prognostic factors in delirium.

Antipsychotics for delirium

BACKGROUND

Delirium occurs in up to 30% of hospitalised patients and is associated with prolonged hospital stay and increased morbidity and mortality. Recently published reports have suggested that the standard drug for delirium, haloperidol, a typical antipsychotic that may cause adverse extrapyramidal symptoms among patients, may be replaced by atypical antipsychotics such as risperidone, olanzapine or quetiapine, that are as effective as haloperidol in controlling delirium, but that have a lower incidence of extrapyramidal adverse effects.

OBJECTIVES

To compare the efficacy and incidence of adverse effects of haloperidol with risperidone, olanzapine, and quetiapine in the treatment of delirium.

SEARCH STRATEGY

The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 7 August 2006 using the search terms:haloperidol or haldol or risperidone or risperdal* or quetiapine or seroquel* or olanzapine or zyprexa* or aminotriazole or sertindole or leponex* or zeldox* or ziprasidone.

SELECTION CRITERIA

Types of studies included unconfounded, randomised trials with concealed allocation of subjects. For inclusion trials had to have assessed patients pre- and post-treatment. Where cross-over studies are included, only data from the first part of the study were examined. Interrupted time series were excluded. Length of trial and number of measurements did not influence the selection of trials for study. Where indicated, individual patient data were requested for further examination.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data from included trials. Data were pooled where possible, and analysed using appropriate statistical methods. Odds ratios of average differences were calculated. Only 'intention to treat' data were included. Analysis included haloperidol treated patients, compared with placebo.

MAIN RESULTS

Three studies were found that satisfied selection criteria. These studies compared haloperidol with risperidone, olanzapine, and placebo in the management of delirium and in the incidence of adverse drug reactions. Decrease in delirium scores were not significantly different comparing the effect of low dose haloperidol (< 3.0 mg per day) with the atypical antipsychotics olanzapine and risperidone (Odds ratio 0.63 (95% CI 10.29 - 1.38; p = 0.25). Low dose haloperidol did not have a higher incidence of adverse effects than the atypical antipsychotics. High dose haloperidol (> 4.5 mg per day) in one study was associated with an increased incidence of extrapyramidal adverse effects, compared with olanzapine. Low dose haloperidol decreased the severity and duration of delirium in post-operative patients, although not the incidence of delirium, compared to placebo controls in one study. There were no controlled trials comparing quetiapine with haloperidol.

AUTHORS' CONCLUSIONS

There is no evidence that haloperidol in low dosage has different efficacy in comparison with the atypical antipsychotics olanzapine and risperidone in the management of delirium or has a greater frequency of adverse drug effects than these drugs. High dose haloperidol was associated with a greater incidence of side effects, mainly parkinsonism, than the atypical antipsychotics. Low dose haloperidol may be effective in decreasing the degree and duration of delirium in post-operative patients, compared with placebo. These conclusions must be tempered by the observation that they are based on small studies of limited scope, and therefore will require further corroborating evidence before they can be translated into specific recommendation for the treatment of delirium.