Drug treatment of delirium: past, present and future

Melatonin and melatonin-receptor agonists to prevent delirium in hospitalized older adults: An umbrella review

BACKGROUND

Alterations in circadian rhythm play an important role in the development of delirium. In this umbrella review, we examined the efficacy of melatonin and ramelteon for delirium prevention in hospitalized older adults.

METHODS

Umbrella review methodology from the Joanna Briggs Institute guided the review process. Only meta-analyses were included. Risk of bias was evaluated using the AMSTAR-2 checklist.

RESULTS

Three meta-analyses were included in this review. The quality of studies was low-to-moderate. Two meta-analyses reported a significant reduction in delirium using melatonin or ramelteon (pooled OR and 95% confidence intervals ranged from 0.41 [0.19-0.86] to 0.63 [0.46-0.87]). Melatonergics significantly reduced delirium on medical units (OR = 0.25, 95% CI 0.07-0.88) but not surgical units (OR = 0.62, 0.16-2.43). Heterogenity was high, with I² ranging from 72.14% to 84%.

CONCLUSIONS

Melatonergics appear to prevent delirium among hospitalized older adults, particularly those on medical units. Based on these results, providers may consider using melatonergics as complements to high-quality multicomponent delirium prevention.

Delirium is associated with frequency band specific dysconnectivity in intrinsic connectivity networks: preliminary evidence from a large retrospective pilot case-control study

Background

Pathophysiological concepts in delirium are not sufficient to define objective biomarkers suited to improve clinical approaches. Advances in neuroimaging have revalued electroencephalography (EEG) as a tool to assess oscillatory network activity in neuropsychiatric disease. Yet, research in the field is limited to small populations and largely confined to postoperative delirium, which impedes generalizability of findings and planning of prospective studies in other populations. This study aimed to assess effect sizes of connectivity measures in a large mixed population to demonstrate that there are measurable EEG differences between delirium and control patients.

Methods

This retrospective pilot study investigated EEG measures as biomarkers in delirium using a case-control design including patients diagnosed with delirium (DSM-5 criteria) and age-/gender-matched controls drawn from a database of 9980 patients (n = 129 and 414, respectively). Assessors were not blinded for groups. Power spectra and connectivity estimates, using the weighted phase log index, of continuous EEG data were compared between conditions. Alterations of information flow through nodes of intrinsic connectivity networks (ICN; default mode, salience, and executive control network) were evaluated in source space using betweenness centrality. This was done frequency specific and network nodes were defined by the multimodal human cerebral cortex parcellation based on human connectome project data.

Results

Delirium and control patients exhibited distinct EEG power, connectivity, and network characteristics (F_(72,540) = 70.3, p < .001; F_(493,1079) = 2.69, p < .001; and F_(718,2159) = 1.14, p = .007, respectively). Connectivity analyses revealed global alpha and regional beta band disconnectivity that was accompanied by theta band hyperconnectivity in delirious patients. Source and network analyses yielded that these changes are not specific to single intrinsic connectivity networks but affect multiple nodes of networks engaged in level of consciousness, attention, working memory, executive control, and salience detection. Effect sizes were medium to strong in this mixed population of delirious patients.

Conclusions

We quantified effect sizes for EEG connectivity and network analyses to be expected in delirium. This study implicates that theta band hyperconnectivity and alpha band disconnectivity may be essential mechanisms in the pathophysiology of delirium. Upcoming prospective studies will build upon these results and evaluate the clinical utility of identified EEG measures as therapeutic and prognostic biomarkers.

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0388-z) contains supplementary material, which is available to authorized users.

Behavioral emergency in the elderly: a descriptive study of patients referred to an Aggression Response Team in an acute hospital

Aim

The management of severely agitated elderly patients is not easy, and limited guidelines are available to assist practitioners. At a Sydney hospital, an Aggression Response Team (ART) comprising clinical and security staff can be alerted when a staff member has safety concerns. Our aims were to describe the patient population referred for ART calls, reasons for and interventions during ART calls, and complications following them.

Methods

Patients 65 years and older referred for ART calls in the emergency department or wards during 2014 were identified using the Incident Information Management System database and medical records were reviewed. Demographic and clinical data were collected.

Results

Of 43 elderly patients with ART calls, 30 had repeat ART calls. Thirty-one patients (72%) had underlying dementia, and 22 (51%) were agitated at the time of admission. The main reasons for ART calls were wandering and physical aggression. Pharmacological sedation was used in 88% of the ART calls, with a range of psychotropics, doses, and routes of administration, including intravenous (19%) and, most commonly, midazolam (53%). Complications were documented in 14% of cases where sedation was used.

Conclusion

We observed a high frequency of pharmacological sedation among the severely agitated elderly, with significant variance in the choice and dose of sedation and a high rate of complications arising from sedation, which may be an underestimate given the lack of post-sedation monitoring. We recommend the development of guidelines on the management of behavioral emergency in the elderly patients, including de-escalation strategies and standardized psychotropic guidelines.

The preventative role of exogenous melatonin administration to patients with advanced cancer who are at risk of delirium: study protocol for a randomized controlled trial

BACKGROUND

Delirium is a very common and distressing neuropsychiatric syndrome in palliative care. Increasing age, the presence of dementia and advanced cancer are well-known predisposing risk factors for delirium development. Sleep-wake cycle disturbance is frequently seen during delirium and melatonin has a pivotal role in the regulation of circadian rhythms. Current evidence across various settings suggests a potential preventative role for melatonin in patients at risk of delirium, but no studies are currently reported in patients with advanced cancer. The aim of this article is to describe the design of a feasibility study that is being conducted to inform a larger randomized, placebo-controlled, double-blind trial (RCT) to evaluate the role of exogenously administered melatonin in preventing delirium in patients with advanced cancer.

METHODS/DESIGN

Adult patients with a cancer diagnosis who are admitted to the palliative care unit will be randomized into a treatment or placebo group. The pharmacological intervention consists of a single daily dose of immediate-release melatonin (3 mg) at 21:00 ± 1 h, from day 1 to day 28 of admission. The primary objective of this initial study is to assess the feasibility of conducting the proposed RCT by testing recruitment and retention rates, appropriateness of study outcome measures, acceptability of study procedures and effectiveness of the blinding process. The primary outcome measure of the proposed larger RCT is time to first inpatient incident episode of delirium. We also plan to collect data on incident rates of delirium and patient-days of delirium, adjusting for length of admission.

DISCUSSION

The outcomes of this feasibility study will provide information on recruitment and retention rates, protocol violation frequency, effectiveness of the blinding process, acceptability of the study procedures, and safety of the proposed intervention. This will inform the design of a fully powered randomized controlled trial to evaluate the preventative role of melatonin administration in patients with advanced cancer.

TRIAL REGISTRATION

Registered with ClinicalTrials.gov: NCT02200172 Registered on 21 July 2014. Health Canada protocol number: BRI-MELAT-2013 (Final approved protocol version (Version 3): 18 June 2014) (Notice of Amended Authorization (NOA) received 14 November 2014).

[Delirium Prevention]

INTRODUCTION

Delirium is the most prevalent neuropsychiatric syndrome in the general hospital. Its presence is a marker of poor prognosis for patients. Its prevention could be the most effective strategy for reducing its frequency and its complications.

OBJECTIVE

To review recent findings and strategies for the prevention of delirium.

METHODOLOGY

A non-systematic review of scientific articles published in the last ten years in Spanish and English. A search was made in databases such as MEDLINE, Cochrane, EMBASE, Ovid, and ScienceDirect, for articles that included the terms, delirium and prevention.

RESULTS

Identification of predisposing and precipitating factors for delirium and a better understanding of the pathophysiological mechanisms underlying the onset of delirium have enabled the implementation of various pharmacological and non-pharmacological strategies in patients at high risk to develop hospital delirium. The studies to prevent delirium have focused on surgical patients. The current evidence supports the daily implementation of non-pharmacological measures to prevent delirium, as they are easy and cost effective. The available evidence is still limited to recommend the daily use of pharmacological strategies in delirium prophylaxis, and there is a consensus against the modest use of antipsychotic drugs in surgical patients and dexmedetomidine in patients in intensive care.

CONCLUSIONS

New high-quality clinical trials and studies involving non-surgical patients are needed to provide more evidence about this subject.

Geriatrics and the Perioperative Surgical Home

An ever-changing health care system with a constantly increasing aging surgical population creates both opportunities for providing improved health care as well as significant challenges. Coordinated health care initiatives are needed if one is to adequately balance the need for evidence-based improved patient outcomes and the often-associated increased costs. In this article the authors postulate that a protocol-driven, multidisciplinary approach may be a pathway for implementing an effective triple aim to health care, especially in a frail geriatric population.

Knowledge and practices of Thai emergency physicians regarding the care of delirious elderly patients

Background

The Society for Academic Emergency Medicine (SAEM) Geriatric Emergency Medicine Task Force recommends assessment of delirium for all elderly emergency department (ED) patients. Little is known about emergency physicians' (EPs) opinions regarding care of delirious elderly patients. We sought to determine the knowledge and practice experience of members of the Thai Association for Emergency Medicine regarding the care of delirious elderly ED patients.

Methods

We surveyed all Thai emergency physicians from July to September 2013 using a brief online survey as this does not include any non-trained physician working in the private/provincial/community EDs, still a significant part of the ED workforce in Thailand.

Results

We had a response rate of 50% (239/474) of which 95% (228/239) completed the survey. Respondents largely reported that <10% of their patients experience delirium. Eighty-five percent of the respondents recognized delirium as a problem that required active intervention, and 76% of the respondents thought it was underdiagnosed in the ED. Only 24% of the respondents reported routinely screening delirium in the ED and 16% reported using a specific screening tool for delirium assessment. Forty-two percent of the respondents reported treating delirium with a long acting benzodiazepine and 29% reported using haloperidol. Forty percent of respondents thought that oversedation was the most common complication associated with drug treatment of delirium.

Conclusions

Basic knowledge and perceptions surrounding the recognition, diagnosis, and treatment of delirium in elderly ED patients by Thai EPs vary. Most of the Thai EPs consider delirium in the ED an emergency condition, while far fewer screen for this condition. Future research and quality improvement should determine which single screening tool is appropriate for EPs in regular practice as well as how to standardize delirium management in the ED.

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.

The pharmacologic management of delirium in children and adolescents

Delirium is a serious and common problem in severely medically ill patients of all ages. It has been less addressed in children and adolescents. Treatment of delirium is predicated on addressing its underlying cause. The management of its symptoms depends on the off-label use of antipsychotics, while avoiding agents that precipitate or worsen delirium. Olanzapine, quetiapine, and risperidone are presently considered first-line drugs, usually replacing haloperidol. Other agents have shown promise, including melatonin to address the sleep disturbance characteristic of delirium, and dexmedetomidine, an α2-agonist, that may facilitate lower doses of benzodiazepines and opioids that may worsen delirium.

Delirium in trauma

Delirium is a common, severe and acute neuropsychiatric syndrome that affects mainly older patients. Delirium is a well-recognised complication of trauma and is important as it is associated with an increase in mortality as well as cognitive and functional decline, increased length of hospital stay and increased risk of institutionalisation on discharge. Recognition and management is challenging and the psychological impact for patients and relatives devastating. This review discusses the current understanding of delirium with specific reference to trauma patients.

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).

Delirium in critically ill patients: epidemiology, pathophysiology, diagnosis and management

Delirium is commonly observed in critically ill patients and is associated with negative outcomes. The pathophysiology of delirium is not completely understood. However, alterations to neurotransmitters, especially acetylcholine and dopamine, inflammatory pathways and an aberrant stress response are proposed mechanisms leading to intensive care unit (ICU) delirium. Detection of delirium using a validated delirium assessment tool makes early treatment possible, which may improve prognosis. Patients at high risk of delirium, especially those with cognitive decline and advanced age, should be identified in the first 24 hours of admission to the ICU. Whether these high-risk patients benefit from haloperidol prophylaxis deserves further study. The effectiveness of a multicomponent, non-pharmacological approach is shown in non-ICU patients, which provides proof of concept for use in the ICU. The few studies on this approach in ICU patients suggest that the burden of ICU delirium may be reduced by early mobility, increased daylight exposure and the use of earplugs. In addition, the combined use of sedation, ventilation, delirium and physical therapy protocols can reduce the frequency and severity of adverse outcomes and should become part of routine practice in the ICU, as should avoidance of deliriogenic medication such as anticholinergic drugs and benzodiazepines. Once delirium develops, symptomatic treatment with antipsychotics is recommended, with haloperidol being the drug of first choice. However, there is limited evidence on the safety and effectiveness of antipsychotics in ICU delirium.

Delirium in hospitalized patients: implications of current evidence on clinical practice and future avenues for research--a systematic evidence review

BACKGROUND

Despite the significant burden of delirium among hospitalized adults, critical appraisal of systematic data on delirium diagnosis, pathophysiology, treatment, prevention, and outcomes is lacking.

PURPOSE

To provide evidence-based recommendations for delirium care to practitioners, and identify gaps in delirium research.

DATA SOURCES

Medline, PubMed, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) information systems from January 1966 to April 2011.

STUDY SELECTION

All published systematic evidence reviews (SERs) on delirium were evaluated.

DATA EXTRACTION

Three reviewers independently extracted the data regarding delirium risk factors, diagnosis, prevention, treatment, and outcomes, and critically appraised each SER as good, fair, or poor using the United States Preventive Services Task Force criteria.

DATA SYNTHESIS

Twenty-two SERs graded as good or fair provided the data. Age, cognitive impairment, depression, anticholinergic drugs, and lorazepam use were associated with an increased risk for developing delirium. The Confusion Assessment Method (CAM) is reliable for delirium diagnosis outside of the intensive care unit. Multicomponent nonpharmacological interventions are effective in reducing delirium incidence in elderly medical patients. Low-dose haloperidol has similar efficacy as atypical antipsychotics for treating delirium. Delirium is associated with poor outcomes independent of age, severity of illness, or dementia.

CONCLUSION

Delirium is an acute, preventable medical condition with short- and long-term negative effects on a patient's cognitive and functional states.

Atypical antipsychotic medications to control symptoms of delirium in children and adolescents

BACKGROUND

Atypical antipsychotics have been documented to be effective in the management of delirium in adults, but despite considerable need, their use has been less studied in pediatric patients.

OBJECTIVE

A retrospective chart review was done to describe the use of atypical antipsychotics in controlling symptoms of delirium in children and adolescents.

METHODS

Pharmacy records at Children's Hospital Los Angeles were reviewed to identify patients to whom antipsychotic agents were dispensed over a 24-month period. Psychiatric inpatient consultations during the same 24-month period were reviewed. Patients 1-18 years old diagnosed with delirium given antipsychotics constituted the study population. Delirium Rating Scale-Revised-98 (DRS-R98) scores were retrospectively calculated, when possible, at time antipsychotic was started to confirm the initial diagnosis of delirium and evaluate symptom severity, and again when antipsychotic was stopped, to assess symptom response.

RESULTS

Olanzapine (n=78), risperidone (n=13), and quetiapine (n=19) were used during the 2 years of the study. Mean patient age, length of treatment, and response were comparable for the three medications. For patients with two DRS-R98 scores available (n=75/110), mean DRS-R98 scores decreased significantly (p<0.001) with antipsychotic without significant adverse side effects.

CONCLUSION

Although randomized placebo-controlled studies are needed, atypical antipsychotic medications appeared to be effective and safe for managing delirium symptoms in pediatric patients while underlying etiology was addressed.

Delirium and refeeding syndrome in anorexia nervosa

OBJECTIVE

To review the literature on delirium and refeeding syndrome in patients with anorexia nervosa (AN) and present case examples in an attempt to identify common clinical features and response to therapy.

METHOD

A comprehensive literature review was completed. In addition to the cases identified in the literature, we present two additional cases of our own.

RESULTS

We identified a total of 10 cases (all female; mean age 19 years old, range 12-29 years); 2/3 of the cases had similar clinical features predating the delirium and during refeeding.

DISCUSSION

Delirium, albeit rare, can be associated with the refeeding syndrome in low weight patients with AN. During the initial refeeding phase, close monitoring of medical, metabolic, and psychological parameters are important in establishing factors that may elevate risk. Early detection and treatment of delirium using nonpharmacologic and pharmacologic means are also important to help minimize the effects of this potentially deadly condition.

Comparative efficacy study of haloperidol, olanzapine and risperidone in delirium

OBJECTIVE

The objective of the study was to assess the efficacy and safety of second-generation antipsychotics olanzapine and risperidone vs. haloperidol in patients of delirium admitted to medical and surgical wards.

METHODS

Prospective follow-up single-blind randomized controlled trials were performed. Consecutive patients with delirium referred to the consultation-liaison psychiatry team were eligible for the study. The study sample comprised 64 patients, with 20 subjects in the haloperidol group, 21 subjects in the risperidone group and 23 subjects in the olanzapine group. A flexible dose regimen (haloperidol -0.25 to 10 mg; risperidone -0.25 to 4 mg; olanzapine -1.25 to 20 mg) was used. Delirium Rating Scale-Revised-98 (DRS-R98) was used as the primary efficacy measure, and mini mental status examination (MMSE) was used as a secondary efficacy measure.

RESULTS

There was no significant difference in mean baseline DRS-R98 severity scores and MMSE scores between the three groups. However, there were a significant reduction in DRS-R98 severity scores and a significant improvement in MMSE scores over the period of 6 days, but there was no difference between the three groups. Four patients in the haloperidol group, six subjects in the risperidone group and two subjects in the olanzapine group experienced some side effects.

CONCLUSIONS

Risperidone and olanzapine are as efficacious as haloperidol in the treatment of delirium.

Melatonin decreases delirium in elderly patients: a randomized, placebo-controlled trial

BACKGROUND

Disturbance in the metabolism of tryptophan and tryptophan-derived compounds (e.g., melatonin) may have a role in the pathogenesis of delirium.

OBJECTIVE

To evaluate the efficacy of low dose exogenous melatonin in decreasing delirium.

DESIGN

A randomized, double-blinded, placebo-controlled study.

SETTING

An Internal Medicine service in a tertiary care centre in London, Ontario, Canada.

PARTICIPANTS

145 individuals aged 65 years or over admitted through the emergency department to a medical unit in a tertiary care hospital.

INTERVENTION

Patients were randomized to receive either 0.5 mg of melatonin or placebo every night for 14 days or until discharge.

MEASUREMENTS

The primary outcome was the occurrence of delirium as determined by Confusion Assessment Method (CAM) criteria.

RESULTS

Of a total of 145 individuals (mean age (standard deviation): 84.5 (6.1) years) 72 were randomly assigned to the melatonin group and 73 to the placebo group. Melatonin was associated with a lower risk of delirium (12.0% vs. 31.0%, p = 0.014), with an odds ratio (OR), adjusted for dementia and co-morbidities of 0.19 (95% confidence intervals (CI): 0.06-0.62). Results were not different when patients with prevalent delirium were excluded.

LIMITATION

An intention to treat analysis was not possible due to loss to follow-up.

CONCLUSION

Exogenous low dose melatonin administered nightly to elderly patients admitted to acute care may represent a potential protective agent against delirium.

Review: delirium in the elderly: a comprehensive review

Delirium is a common neuropsychiatric syndrome in the elderly characterized by concurrent impairments in cognition and behaviors. The etiologies for delirium are often multifactorial and are due to underlying medical illnesses and/or due to medication effect. The diagnosis of delirium is often missed in elderly patients and this condition may be mislabeled as depression or dementia. Untreated, delirium can have devastating consequences in the elderly with high rates of morbidity and mortality. Available evidence indicates that early detection, reduction of risk factors, and better management of this condition can decrease its morbidity rates. In this review, we discuss the etiology, neurobiology, diagnosis, prevention, and treatments for this potentially lethal condition in the elderly.

Preventing postoperative complications in the elderly

Postoperative complications are directly related to poor surgical outcomes in the elderly. This review outlines evidence based quality initiatives focused on decreasing neurologic, cardiac, and pulmonary complications in the elderly surgical patient. Important anesthesia quality initiatives for prevention of delirium, the most common neurologic complication in elderly surgical patients, are outlined. There are few age-specific quality measures aimed at prevention of cardiac and pulmonary complications. However, some recommendations for adults can be applied to the geriatric surgical population. In the future, process measures may provide a more global assessment of quality in the elderly surgical population.

Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: a multicentre, double-blind, placebo-controlled randomised trial

BACKGROUND

Delirium is frequently diagnosed in critically ill patients and is associated with adverse outcome. Impaired cholinergic neurotransmission seems to have an important role in the development of delirium. We aimed to establish the effect of the cholinesterase inhibitor rivastigmine on the duration of delirium in critically ill patients.

METHODS

Patients (aged ≥18 years) who were diagnosed with delirium were enrolled from six intensive care units in the Netherlands, and treated between November, 2008, and January, 2010. Patients were randomised (1:1 ratio) to receive an increasing dose of rivastigmine or placebo, starting at 0·75 mL (1·5 mg rivastigmine) twice daily and increasing in increments to 3 mL (6 mg rivastigmine) twice daily from day 10 onwards, as an adjunct to usual care based on haloperidol. The trial pharmacist generated the randomisation sequence by computer, and consecutively numbered bottles of the study drug according to this sequence to conceal allocation. The primary outcome was the duration of delirium during hospital admission. Analysis was by intention to treat. Duration of delirium was censored for patients who died or were discharged from hospital while delirious. Patients, medical staff, and investigators were masked to treatment allocation. Members of the data safety and monitoring board (DSMB) were unmasked and did interim analyses every 3 months. This trial is registered with ClinicalTrials.gov, number NCT00704301.

FINDINGS

Although a sample size of 440 patients was planned, after inclusion of 104 patients with delirium who were eligible for the intention-to-treat analysis (n=54 on rivastigmine, n=50 on placebo), the DSMB recommended that the trial be halted because mortality in the rivastigmine group (n=12, 22%) was higher than in the placebo group (n=4, 8%; p=0·07). Median duration of delirium was longer in the rivastigmine group (5·0 days, IQR 2·7-14·2) than in the placebo group (3·0 days, IQR 1·0-9·3; p=0·06).

INTERPRETATION

Rivastigmine did not decrease duration of delirium and might have increased mortality so we do not recommend use of rivastigmine to treat delirium in critically ill patients.

FUNDING

ZonMw, the Netherlands Brain Foundation, and Novartis.

Three patients with cancer who developed rapid-eye-movement sleep behavior disorder

This article discusses the clinical significance of differentiating parasomnia, such as rapid-eye-movement (REM) sleep behavior disorder (RBD), from delirium in patients with advanced cancer. We describe three patients with advanced cancer who presented with aberrant behavior at night. All three patients developed violent behaviors when they were administered opioids and/or chemotherapy. Polysomnography (PSG) showed REM sleep with tonic electromyography. Previous treatment with neuroleptics had failed to improve their problematic behaviors. Diagnosis was made using criteria for REM behavior disorder of the International Classification of Sleep Disorders, 2nd edition, and PSG. Clonazepam (0.5 mg/day) was administered orally once at night. After treatment with clonazepam, aberrant and violent behaviors were improved. It should be noted that it is not rare for patients with advanced cancer to present with parasomnia, such as RBD, although organic brain syndrome, such as delirium, is more prevalent. Therefore, it is necessary to provide adequate assessment and treatment of aberrant behaviors in cancer patients.

Delirium in intensive care unit patients

Delirium is defined as a disturbance of consciousness with cognitive changes or perceptual disturbances, which has developed over a short period of time, and is caused by a medical condition or a postsurgical state. Although historically dismissed as an inconvenient and transient problem, recent studies have reported that delirium is associated with more complications, increased length of hospital stay, and higher mortality. Although delirium is a prevalent condition after cardiothoracic surgery and in the intensive care unit (ICU), the condition appears to be largely underdiagnosed. Several detection tools have been developed for routine monitoring of delirium by nonpsychiatric personnel in the ICU, such as the Confusion Assessment Method for the Intensive Care Unit and the Intensive Care Delirium Screening Checklist. Management includes treatment of underlying disorders, nonpharmacological measures and symptomatic drug therapy. There is a need for well-designed randomized, double-blind, placebo-controlled trials on drug treatment.

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.

Delirium, a 'confusing' condition in general hospitals: The experience of a Consultation-Liaison Psychiatry Unit in Greece

BACKGROUND/AIMS

A plethora of studies showed that delirium is common in hospitalized populations. We aimed to examine the characteristics of delirium patients referred to our Consultation-Liaison Psychiatry Unit (CLPU).

METHODS

Our CLPU database was used to obtain data of all referred patients admitted to our hospital and diagnosed with delirium. All referred nondelirious patients served as controls.

RESULTS

During one year, 483 patients were referred to the CLPU. Ninety-three (19.3%) were diagnosed with delirium. Delirious patients were older than nondelirious patients (P < 0.001), with 76.3% aged over 70 years. The majority of the referrals came from surgical specialties. Common etiological factors were fluid and electrolyte imbalance (29%), fractures (28%) and infections (24%), but laboratory tests for the investigation of the etiology prior to the consultation had been performed in only 12 patients (12.9%). The syndrome resulted in prolonged hospitalization and greater use of CLPU services.

CONCLUSIONS

Referrals for delirium are frequent in CLPUs in Greece. Although delirium is common, it remains a 'confusing' condition for health practitioners. The under-diagnosis of delirium, the prolonged hospitalization and the time that the CLPU dedicated to these patients underlines the role of the CLPU psychiatrists in the management of the syndrome.

The assessment and management of delirium in cancer patients

Delirium remains the most common and distressing neuropsychiatric complication in patients with advanced cancer. Delirium causes significant distress to patients and their families, and continues to be underdiagnosed and undertreated. The most frequent, consistent, and, at the same time, reversible etiology is drug-induced delirium resulting from opioids and other psychoactive medications. The objective of this narrative review is to outline the causes of delirium in advanced cancer, especially drug-induced delirium, and the diagnosis and management of opioid-induced neurotoxicity. The early symptoms and signs of delirium and the use of delirium-specific assessment tools for routine delirium screening and monitoring in clinical practice are summarized. Finally, management options are reviewed, including pharmacological symptomatic management and also the provision of counseling support to both patients and their families to minimize distress.

Postoperative delirium in the elderly surgical patient

Delirium is a common complication in the geriatric population following cardiac and noncardiac procedures. Postoperative delirium is a significant financial burden on the United States health care system and is independently associated with prolonged hospital stay, increased risk of early and long term mortality, increased physical dependence, and an increased rate of nursing home placement. The Confusion Assessment Method (CAM) is a bedside rating scale developed to assist nonpsychiatrically trained clinicians in the rapid and accurate diagnosis of delirium. The CAM has been adapted for use in ventilated intensive care unit (ICU) patients in the form of the CAM-ICU. The onset of delirium involves an interaction between predisposing and precipitating risk factors for delirium. The mainstay of delirium management is prevention. The approach involves control or elimination of modifiable risk factors. It is controversial whether anesthetic technique determines delirium. However, important modifiable risk factors under the anesthesiologist's control include adequate postoperative pain management, careful drug selection, and embracing and participating in a multidisciplinary care model for these complicated patients.

Delirium in elderly adults: diagnosis, prevention and treatment

Delirium is a common and serious acute neuropsychiatric syndrome with core features of inattention and global cognitive dysfunction. The etiologies of delirium are diverse and multifactorial and often reflect the pathophysiological consequences of an acute medical illness, medical complication or drug intoxication. Delirium can have a widely variable presentation, and is often missed and underdiagnosed as a result. At present, the diagnosis of delirium is clinically based and depends on the presence or absence of certain features. Management strategies for delirium are focused on prevention and symptom management. This article reviews current clinical practice in delirium in elderly individuals, including the diagnosis, treatment, outcomes and economic impact of this syndrome. Areas of future research are also discussed.

Delirium in elderly adults: diagnosis, prevention and treatment

Delirium is a common and serious acute neuropsychiatric syndrome with core features of inattention and global cognitive dysfunction. The etiologies of delirium are diverse and multifactorial and often reflect the pathophysiological consequences of an acute medical illness, medical complication or drug intoxication. Delirium can have a widely variable presentation, and is often missed and underdiagnosed as a result. At present, the diagnosis of delirium is clinically based and depends on the presence or absence of certain features. Management strategies for delirium are focused on prevention and symptom management. This article reviews current clinical practice in delirium in elderly individuals, including the diagnosis, treatment, outcomes and economic impact of this syndrome. Areas of future research are also discussed.

Delirium: sifting through the confusion

Delirium is commonly encountered in the hospital setting, particularly in the intensive care unit. However, the diagnosis is often missed, due in part to the nature of the illness, fluctuating levels of consciousness, and varied presentation. Even when it is recognized, delirium can be hard to manage, with multiple factors contributing to its course. In this article, we review the latest information regarding the underlying mechanisms of the syndrome and treatment options available. This is accomplished by examining two complex cases encountered at a university medical center-based psychosomatic service.