An update on the use of antipsychotics in the treatment of delirium

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.

Fever and neurologic conditions

Neurologic conditions are categorized as either those that cause a change in mental status or those that create a focal finding on physical examination. Neurologic abnormality associated with fever can be caused by a primary neurologic condition or one that does not originate in the central nervous system. Optimal management of such conditions requires high clinical suspicion and a broad differential diagnosis, which facilitates rapid recognition and effective treatment. A thorough history and physical examination are key determinants in accurately diagnosing neurologic conditions associated with fever, often requiring acquisition of collateral information from persons other than the patient.

The diagnosis and management of delirium in infancy

OBJECTIVE

Atypical antipsychotics have been documented to be effective in the management of delirium in adults and older children, but despite considerable need, their use has been less studied in the very young. A retrospective chart review was undertaken to describe the use of atypical antipsychotics in controlling symptoms of delirium in infants and toddlers.

METHODS

All psychiatric inpatient consultations performed during a 3 year period were reviewed to identify children <36 months old diagnosed with delirium. Delirium Rating Scale (DRS) scores were retrospectively calculated when the antipsychotic was initiated and discontinued, to confirm the diagnosis of delirium and evaluate symptom severity, and then to assess symptom response to pharmacologic intervention.

RESULTS

There were 10 boys and 9 girls in the study population (ages 7-30 months, mean 20.5 months). Olanzapine (n=16) and risperidone (n=3) were used, and length of treatment and response were comparable for both medications. Mean DRS scores decreased significantly (p<0.001) with antipsychotic administration, without significant adverse side effects.

CONCLUSIONS

Although randomized placebo controlled studies are needed to better characterize the indications, risks, and benefits, these atypical antipsychotic medications appeared to be effective and safe for managing delirium symptoms in very young pediatric patients.

Delirious mania: can we get away with this concept? A case report and review of the literature

Background. Delirious mania (DM) as a clinical entity is well described, yet is often unrecognized in clinical practice. While most often misdiagnosed as acute psychotic episodes of organic delirium, these patients meet the criteria for mania with attendant delirium and pose therapeutic challenges. In addition to the case presentation, this paper also discusses the available literature on DM. Case Presentation. A 29-year-old man with DM was treated with a combination of electroconvulsive therapy (ECT), divalproex 2000 mg/day, loxapine 100 mg/day, and lorazepam 4 mg/day. He demonstrated clinically significant improvement by day 10, which persisted through the twelve-month follow-up period. Conclusions. DM is a severe psychiatric syndrome which should be accurately diagnosed. Patients with DM should be treated aggressively, especially with ECT. Lack of recognition of DM can lead to serious morbidity or fatal outcomes. Though the concept of DM is well established, recent psychiatric literature does not make a mention of this life threatening yet treatable condition. We propose that there is a dire need to keep this concept alive.

Assessment and management of delirium: a focus on hepatic encephalopathy

This purpose of this article is to promote comprehensive assessment, differential evaluation and provision of care which optimizes benefit while minimizing burden. Delirium is a debilitating neuropsychiatric complication that is highly prevalent in palliative care. It is multifactorial and may be related to infection, disease progression, metabolic state or medication toxicity. There are three proposed sub-types of delirium with the hypoactive/ hypoalert variant being most often underdiagnosed and undertreated. The inadequate management of all types of delirium is associated with increased personal and family distress, lengthier hospital stays, and escalating healthcare costs. This article reviews the assessment, diagnosis and treatment for delirium in general and hepatic encephalopathy in particular. A number of valid and reliable tools are discussed, as they assist in screening, symptom appraisal, diagnosis, and treatment planning. It is recognized that nurses are particularly well positioned to make bedside observations, to document changes over time, and to educate and support patients and their families. Searching for the etiology of delirium, developing individualized plans of care consistent with patient goals, and endorsing the benefit of consultation/referral are discussed as key roles for palliative care providers from all disciplines. New and novel therapies in the management of hepatic encephalopathy are discussed, as they expand treatment options for patients at all points along the trajectory of liver disease.

Clinical features of delirious mania: a series of five cases and a brief literature review

BACKGROUND

Little is known about the cause and psychopathology of delirious mania, a type of disorder where delirium and mania occur at the same time. This condition still has no formal diagnostic classification. To provide more information about this potentially life-threatening condition, we studied five patients with delirious mania.

METHODS

We describe the cases of five patients with delirious mania admitted to an acute inpatient psychiatric unit between January 2005 and January 2007, and discuss the cases in the context of a selective review of the clinical literature describing the clinical features and treatment of delirious mania.

RESULTS

Two patients had two episodes of delirious mania. Delirium usually resolved faster than mania though not always the case. Delirious mania remitted within seven sessions of the electroconvulsive therapy (ECT).

CONCLUSIONS

Delirious mania is a potentially life-threatening but under-recognized neuropsychiatric syndrome. Delirious mania that is ineffectively treated may induce a new-onset manic episode or worsen an ongoing manic episode, and the patient will need prolonged hospitalization. Delirious mania also has a close relationship with catatonia. Early recognition and aggressive treatment, especially with electroconvulsive therapy, can significantly reduce morbidity and mortality.

Delirium: a review

Delirium affects a diverse patient population, may present with highly variable clinical features, is a source of distress for patients and their caregivers, prolongs hospital stays and may herald a poor prognosis. Many cases of delirium are reversible and therefore a full history, physical examination and investigations should be performed. Ahigh degree of suspicion is required for detecting delirium and thorough investigations are necessary in order to determine the underlying etiology and to maximize the potential for reversibility. The following review outlines important aspects of a clinical approach to delirium, the differential diagnosis of delirium, investigation of a patient presenting with delirium, management of delirium, the pathophysiology of delirium and the prognosis accompanying delirium.

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.

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.