Polypharmacy and Delirium in Critically Ill Older Adults: Recognition and Prevention

Pharmacotherapy assessment and adverse drug reactions in older patients admitted to intensive care

INTRODUCTION

Older patients are more susceptible to medication use, and physiological changes resulting from aging and organic dysfunctions presented by critically ill patients may alter the pharmacokinetic or pharmacodynamic behavior. Thus, critically ill older people present greater vulnerability to the occurrence of pharmacotherapeutic problems.

OBJECTIVE

To evaluate pharmacotherapy and the development of potential adverse drug reactions (ADRs) in older patients admitted to an intensive care unit (ICU).

METHOD

A cohort study was conducted in an ICU for adults of a Brazilian University Hospital during a 12-month period. The patients' pharmacotherapy was evaluated daily, considering the occurrence of ADRs and drug-drug interactions (DDIs), the use of potentially inappropriate medications (PIMs) for older people, and the pharmacotherapy anticholinergic burden (ACB). A trigger tool was used for active search of ADRs, with subsequent causality evaluation. PIM use was evaluated by means of the Beers criteria and the STOPP/START criteria. The ABC scale was employed to estimate ACB. The Micromedex® and Drugs.com® medication databases were employed to evaluate the DDIs.

RESULTS

The sample of this study consisted of 41 patients, with a mean age of 66.8 years old (±5.2). The 22 triggers used assisted in identifying 15 potential ADRs, and 26.8% of the patients developed them. The mean estimated ACB score was 3.0 (±1.8), and the patients used 3.1 (±1.4) and 3.3 (±1.6) PIMs according to the Beers and the STOPP criteria, respectively. A total of 672 DDIs were identified, with a mean of 16.8 (±9.5) DDIs/patient during ICU hospitalization. Our findings show an association between occurrence of ADRs in the ICU and polypharmacy (p=.03) and DDIs (p=.007), corroborating efforts for rational medication use as a preventive strategy.

CONCLUSIONS

Using tools to evaluate the pharmacotherapy for older people in intensive care can assist in the recognition and prevention of pharmacotherapeutic problems, with emphasis on the identification of ADRs through the observation of triggers and subsequent causality analysis.

Pharmacologic Sleep Aids in the Intensive Care Unit: A Systematic Review

Background: Patients in the intensive care unit (ICU) often experience poor sleep quality. Pharmacologic sleep aids are frequently used as primary or adjunctive therapy to improve sleep, although their benefits in the ICU remain uncertain. This review aims to provide a comprehensive assessment of the objective and subjective effects of medications used for sleep in the ICU, as well as their adverse effects. Methods: PubMed, Web of Science, Scopus, Embase, and Cochrane Central Register of Controlled Trials were systematically searched from their inception until June 2023 for comparative studies assessing the effects of pharmacologic sleep aids on objective and subjective metrics of sleep. Results: Thirty-four studies with 3498 participants were included. Medications evaluated were melatonin, ramelteon, suvorexant, propofol, and dexmedetomidine. The majority of studies were randomized controlled trials. Melatonin and dexmedetomidine were the best studied agents. Objective sleep metrics included polysomnography (PSG), electroencephalography (EEG), bispectral index, and actigraphy. Subjective outcome measures included patient questionnaires and nursing observations. Evidence for melatonin as a sleep aid in the ICU was mixed but largely not supportive for improving sleep. Evidence for ramelteon, suvorexant, and propofol was too limited to offer definitive recommendations. Both objective and subjective data supported dexmedetomidine as an effective sleep aid in the ICU, with PSG/EEG in 303 ICU patients demonstrating increased sleep duration and efficiency, decreased arousal index, decreased percentage of stage N1 sleep, and increased absolute and percentage of stage N2 sleep. Mild bradycardia and hypotension were reported as side effects of dexmedetomidine, whereas the other medications were reported to be safe. Several ongoing studies have not yet been published, mostly on melatonin and dexmedetomidine. Conclusions: While definitive conclusions cannot be made for most medications, dexmedetomidine improved sleep quantity and quality in the ICU. These benefits need to be balanced with possible hemodynamic side effects.

Pharmacotherapy consideration of thrombolytic medications in COVID-19-associated ARDS

BACKGROUND

In late 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which is responsible for coronavirus disease (COVID-19), was identified as the new pathogen to lead pneumonia in Wuhan, China, which has spread all over the world and developed into a pandemic. Despite the over 1 year of pandemic, due to the lack of an effective treatment plan, the morbidity and mortality of COVID-19 remains high. Efforts are underway to find the optimal management for this viral disease.

MAIN BODY

SARS-CoV-2 could simultaneously affect multiple organs with variable degrees of severity, from mild to critical disease. Overproduction of pro-inflammatory mediators, exacerbated cellular and humoral immune responses, and coagulopathy such as Pulmonary Intravascular Coagulopathy (PIC) contributes to cell injuries. Considering the pathophysiology of the disease and multiple microthrombi developments in COVID-19, thrombolytic medications seem to play a role in the management of the disease. Beyond the anticoagulation, the exact role of thrombolytic medications in the management of patients with COVID-19-associated acute respiratory distress syndrome (ARDS) is not explicit. This review focuses on current progress in underlying mechanisms of COVID-19-associated pulmonary intravascular coagulopathy, the historical use of thrombolytic drugs in the management of ARDS, and pharmacotherapy considerations of thrombolytic therapy, their possible benefits, and pitfalls in COVID-19-associated ARDS.

CONCLUSIONS

Inhaled or intravenous administration of thrombolytics appears to be a salvage therapy for severe ARDS associated with COVID-19 by prompt attenuation of lung injury. Considering the pathogenesis of COVID-19-related ARDS and mechanism of action of thrombolytic agents, thrombolytics appear attractive options in stable patients without contraindications.

Polypharmacy Management in the Older Adults: A Scoping Review of Available Interventions

Background: Polypharmacy paves the way for non-adherence, adverse drug reactions, negative health outcomes, increased use of healthcare services and rising costs. Since it is most prevalent in the older adults, there is an urgent need for introducing effective strategies to prevent and manage the problem in this age group. Purpose: To perform a scoping review critically analysing the available literature referring to the issue of polypharmacy management in the older adults and provide narrative summary. Data sources: Articles published between January 2010-March 2018 indexed in CINHAL, EMBASE and PubMed addressing polypharmacy management in the older adults. Results: Our search identified 49 papers. Among the identified interventions, the most often recommended ones involved various types of drug reviews based on either implicit or explicit criteria. Implicit criteria-based approaches are used infrequently due to their subjectivity, and limited implementability. Most of the publications advocate the use of explicit criteria, such as e.g. STOPP/START, Beers and Medication Appropriateness Index (MAI). However, their applicability is also limited due to long lists of potentially inappropriate medications covered. To overcome this obstacle, such instruments are often embedded in computerised clinical decision support systems. Conclusion: Multiple approaches towards polypharmacy management are advised in current literature. They vary in terms of their complexity, applicability and usability, and no "gold standard" is identifiable. For practical reasons, explicit criteria-based drug reviews seem to be advisable. Having in mind that in general, polypharmacy management in the older adults is underused, both individual stakeholders, as well as policymakers should strengthen their efforts to promote these activities more strongly.

L-carnitine: Searching for New Therapeutic Strategy for Sepsis Management

In this review, we discussed the biological targets of carnitine, its effects on immune function, and how L-carnitine supplementation may help critically ill patients. L-carnitine is a potent antioxidant. L-carnitine depletion has been observed in prolonged intensive care unit (ICU) stays, while L-carnitine supplementation has beneficial effects in health promotion and regulation of immunity. It is essential for the uptake of fatty acids into mitochondria. By inhibiting the ubiquitin-proteasome system, down-regulation of apelin receptor in cardiac tissue, and reducing β-oxidation of fatty acid, carnitine may decrease vasopressor requirement in septic shock and improve clinical outcomes of this group of patients. We also have an overview of animal and clinical studies that have been recruited for evaluating the beneficial effects of L-carnitine in the management of sepsis/ septic shock. Additional clinical data are required to evaluate the optimal daily dose and duration of L-carnitine supplementation.

Potentially inappropriate medication use in elderly patients treated in intensive care units: A cross-sectional study using 2019 Beers, STOPP/v2 Criteria and EU(7)-PIM List

OBJECTIVE

To determine the prevalence of and the risk factors for Potentially Inappropriate Medication (PIM), the drug groups most commonly evaluated as PIMs in elderly patients in the ICUs by using 2019 Beers Criteria, STOPP version 2 (v2) Criteria and EU(7)-PIM List. The relation between mortality rate and length of ICU stay with PIMs was also examined.

METHODS

This was a cross sectional study conducted on patients aged ≥65 years, treated in ICUs (n = 139) between June 8, 2020, and January 11, 2021. Patients' demographic characteristics, clinical data and laboratory findings about the drugs used were collected prospectively. PIMs were evaluated according to each of the criteria applied. Relationship of dependent and independent variables was evaluated using chi-square analysis, t-test and logistic regression analysis. P < .05 was considered statistically significant.

RESULTS

The number of patients with at least 1 PIM according to three criteria was 118 (84.9%) (80.6%, 59.7%, 48.2%, Beers, STOPP/v2 and EU(7)-PIM List, respectively). In the univariate analysis, receiving renal replacement therapy and high number of drugs were the covariates that significantly affected the presence of PIM according to all three criteria (P < .05). Combined use of anxiolytics and opioids in Beers Criteria (58.3%), antipsychotics (26.6%) in STOPP/v2 Criteria, and antiarrhythmics (23.7%) in EU(7)-PIM List were the drugs that caused PIM at most. No relationship was found between the presence of PIM and mortality. The length of ICU stay was determined significantly longer in the presence of PIM according to Beers Criteria (P = .028).

CONCLUSIONS

In this study, the prevalence of PIM was determined higher in elderly patients in ICU. Our results supported that 2019 Beers Criteria for ICU patients seems to be more directive in detecting PIMs and determining the prognosis. Reducing the number of drugs administered may be the first step to decrease PIMs in elderly patients in ICU and to maintain the treatment safely.

Delirium and Its Pharmacological Causes in Older People, Part 1

Delirium is a syndrome that can arise from many causes or underlying conditions, and though it has been reported in younger patients, it is more prevalent in older people, though it can occur in other age groups as well. Identifying delirium is challenging in older people because of the coexistence of underlying dementia or depression, which may further complicate the presentation. Drug-induced delirium is one of the major causes of delirium, and evaluation of this potential cause or contribution is an important component of the evaluation process, since it can lead to poor patient outcomes. This article will review the epidemiology, pathophysiology, evaluation, diagnostic process, and causes of delirium in older people, with a focus on the pharmacological causes.

Characterization of Nocturnal Neuroactive Medication Use and Related Sleep Documentation in Critically Ill Adults

We retrospectively characterized scheduled, newly initiated, nocturnal neuroactive medication use, and related clinician documentation, in a cohort of consecutive adults admitted greater than or equal to 24 hours to seven different medical/surgical ICUs at two academic centers who had not received a scheduled nocturnal neuroactive medication prior to admission, over a 5-month period (April 1, 2017, to August 31, 2017). A total of 207 different newly initiated, scheduled nocturnal neuroactive medication orders were written (melatonin agonist 101 [48.8%], antipsychotic 80 [38.6%], antidepressant 17 [8.2%], benzodiazepine 9 [4.3%]) in 189 (9.7%) of the 1,955 patients. Among the 1,553 nights, the 189 patients spent in the ICU, a scheduled nocturnal neuroactive medication was administered on 1,103 (71%), an “as needed” nocturnal neuroactive medication was solely administered on 183 (11.8%), delirium occurred on 736 (47.4%), and nurses were twice as likely as physicians (28.8% vs 11.4%; p < 0.0001) to document a note about sleep quality. Among the 69.8% of patients discharged to the floor, and the 64.5% from the hospital, the scheduled nocturnal neuroactive medication was continued in 85.6% and 87.3%, respectively. Scheduled nocturnal neuroactive medication initiation is common, often continued beyond hospital discharge, and poorly documented.

Chronic Post-Surgical Pain in the Frail Older Adult

Older adults are the fastest growing segment of the population and surgical procedures in this group increase each year. Chronic post-surgical pain is an important consideration in the older adult as it affects recovery, physical functioning, and overall quality of life. It is increasingly recognized as a public health issue but there is a need to improve our understanding of the disease process as well as the appropriate treatment and prevention. Frailty, delirium, and cognition influence post-operative outcomes in older adults and have been implicated in the development of chronic post-surgical pain. Further research must be conducted to fully understand the role they play in the occurrence of chronic post-surgical pain in the older adult. Additionally, careful attention must be given to the physiologic, cognitive, and comorbidity differences between the older adult and the general population. This is critical for elucidating the proper chronic post-surgical pain treatment and prevention strategies to ensure that the older adult undergoing surgical intervention will have an appropriate and desirable post-operative outcome.

Approaches to Optimize Medication Data Analysis in Clinical Cohort Studies

OBJECTIVES

Methods for pharmacoepidemiologic studies of large-scale data repositories are established. Although clinical cohorts of older adults often contain critical information to advance our understanding of medication risk and benefit, the methods best suited to manage medication data in these samples are sometimes unclear and their degree of validation unknown. We sought to provide researchers, in the context of a clinical cohort study of delirium in older adults, with guidance on the methodological tools to use data from clinical cohorts to better understand medication risk factors and outcomes.

DESIGN

Prospective cohort study.

SETTING

The Successful Aging After Elective Surgery (SAGES) prospective cohort.

PARTICIPANTS

A total of 560 older adults (aged ≥70 years) without dementia undergoing elective major surgery.

MEASUREMENTS

Using the SAGES clinical cohort, methods used to characterize medications were identified, reviewed, analyzed, and distinguished by appropriateness and degree of validation for characterizing pharmacoepidemiologic data in smaller clinical data sets.

RESULTS

Medication coding is essential; the American Hospital Formulary System, most often used in the United States, is not preferred over others. Use of equivalent dosing scales (e.g., morphine equivalents) for a single medication class (e.g., opioids) is preferred over multiclass analgesic equivalency scales. Medication aggregation from the same class (e.g., benzodiazepines) is well established; the optimal prevalence breakout for aggregation remains unclear. Validated scale(s) to combine structurally dissimilar medications (e.g., anticholinergics) should be used with caution; a lack of consensus exists regarding the optimal scale. Directed acyclic graph(s) are an accepted method to conceptualize causative frameworks when identifying potential confounders. Modeling-based strategies should be used with evidence-based, a priori variable-selection strategies.

CONCLUSION

As highlighted in the SAGES cohort, the methods used to classify and analyze medication data in clinically rich cohort studies vary in the rigor by which they have been developed and validated.

Polypharmacy After Elective Orthopaedic Surgery

Polypharmacy is common, especially among older patients. Polypharmacy can lead to adverse patient outcomes and increased healthcare costs. After elective hip or knee arthroplasty, several new medications are prescribed, which can contribute to polypharmacy, although these medications are necessary in the postoperative period. Although some instances of polypharmacy may be appropriate, many are not. Nurse practitioners play a vital role in identifying and preventing inappropriate polypharmacy in the postoperative period and can develop individualized therapy plans for each patient to provide safe medication use in patients. This would be beneficial in the orthopaedic surgery postoperative period because of the introduction of several new medications.

Characteristics of Nonpharmacological Interventions for Pain Management in the ICU: A Scoping Review

Pain relief in the intensive care unit (ICU) is of particular concern since patients are exposed to multiple painful stimuli associated with care procedures. Considering the adverse effects of pharmacological approaches, particularly in vulnerable populations such as the elderly, the use of non-pharmacological interventions has recently been recommended in the context of critical care. The main goal of this scoping review was to systematically map the research done on non-pharmacological interventions for pain management in ICU adults and describe the characteristics of these interventions. A wide variety of non-pharmacological interventions have been tested, with music and massage therapies being the most frequently used. An interesting new trend is the use of combined or bundle interventions. Lastly, it was observed that these interventions have not been studied in specific subgroups, such as the elderly, women, and patients unable to self-report.

Development of disturbance of consciousness is associated with increased severity in acute pancreatitis

BACKGROUND

Disturbance of consciousness (DOC) may develop in acute pancreatitis (AP). In clinical practice, it is known that DOC may worsen the patient's condition, but we have no exact data on how DOC affects the outcome of AP.

METHODS

From the Hungarian Pancreatic Study Groups' AP registry, 1220 prospectively collected cases were analyzed, which contained exact data on DOC, included patients with confusion, delirium, convulsion, and alcohol withdrawal, answering a post hoc defined research question. Patients were separated to Non-DOC and DOC, whereas DOC was further divided into non-alcohol related DOC (Non-ALC DOC) and ALC DOC groups. For statistical analysis, independent sample t-test, Mann-Whitney, Chi-squared, or Fisher exact test were used.

RESULTS

From the 1220 patients, 47 (3.9%) developed DOC, 23 (48.9%) cases were ALC DOC vs. 24 (51.1%) Non-ALC DOC. Analysis between the DOC and Non-DOC groups showed a higher incidence of severe AP (19.2% vs. 5.3%, p < 0.001), higher mortality (14.9% vs. 1.7%, p < 0.001), and a longer length of hospitalization (LOH) (Me = 11; IQR: 8-17 days vs. Me = 9; IQR: 6-13 days, p = 0.049) respectively. Patients with ALC DOC developed more frequently moderate AP vs. Non-ALC DOC (43.5% vs. 12.5%), while the incidence of severe AP was higher in Non-ALC vs. ALC DOC group (33.3% vs. 4.4%) (p < 0.001). LOH showed a tendency to be longer in Non-ALC DOC compared to ALC DOC, respectively (Me:13; IQR:7-20 days vs. Me:9.5; IQR:8-15.5 days, p = 0.119).

CONCLUSION

DOC during AP is associated with a higher rate of moderate and severe AP and increases the risk of mortality.

Polypharmacy in older adults: the role of the multidisciplinary team

Patients over the age 65 are a quickly expanding segment of the US population and represent a large percentage of patients requiring inpatient care. Older adults are more likely to experience polypharmacy and adverse drug effects. This review explains the risks of polypharmacy and potentially inappropriate medications in the elderly. Specific classes of medications frequently used in older adults in acute care settings are examined, including anticholinergic, sedative hypnotics, and antipsychotic medications. We discuss strategies aimed at addressing polypharmacy in this population including a drug regimen review (which is distinct from medication reconciliation), screening tools, pharmacist-led interventions, and computer-based strategies in the context of current literature and research findings. We provide a summary of general guidelines that may be helpful for geriatricians and hospitalists in improving patient care and clinical outcomes.

Predisposing and precipitating factors for delirium in neurology: a prospective cohort study of 1487 patients

INTRODUCTION

Predisposing and precipitating factors for delirium are well known; however, their interaction and impact on delirium in neurological patients remains largely unknown. Therefore, those factors were evaluated in hospitalized patients with neurological disorders.

METHODS

In this prospective cohort study, 1487 neurological patients were included, 356 patients with delirium and 1131 without delirium. Relevant neurological- and medical-related clusters were assessed with multiple regression analyses, prediction models, and cluster analysis evaluating their association with delirium.

RESULTS

The 1-year incidence of delirium in this cohort was 23.9%. Delirium developed in 31% of patients with stroke, in 39.5% with epilepsy, and in 58.4% with ICH. The most relevant predisposing factors were substance-use disorders (OR 4.24, 2.28-7.78, p < 0.001), advanced age (OR 3.44, CI 2.40-4.92, p < 0.001), and neurodegenerative disorders (OR 2.58, CI 1.47-4.54, p = 0.001). The most relevant precipitating factors were meningitis (OR 21.52, CI 1.22-379.83, p = 0.036), acute renal failure (OR 10.01, CI 1.13-88.73, p = 0.039), and intracranial hemorrhage (OR 3.62, CI 2.08-6.30, p < 0.001). Delirious patients were hospitalized 6 days longer, had higher in-hospital mortality, and were discharged more often to nursing homes and rehabilitation. Best predictor for delirium was the coexistence of advanced age with epilepsy (58.3%, p < 0.001), while patients aged < 65 years without epilepsy and stroke rarely developed delirium (5.1%, p < 0.001).

CONCLUSIONS

Delirium is common in elder neurological patients and associated with worse outcome. Primary cerebral conditions most frequently precipitate delirium in neurology. Neurologists are advised to monitor symptoms of delirium in the presence of risk factors to enable both timely diagnostic work-up and management of delirium.