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Noda Y, Tarasawa K, Fushimi K, Fujimori K. Drug Treatment for Patients with Postoperative Delirium and Consultation-Liaison Psychiatry in Japan: A Retrospective Observational Study of a Nationwide Hospital Claims Database. ANNALS OF CLINICAL EPIDEMIOLOGY 2021; 3:116-126. [PMID: 38505471 PMCID: PMC10760470 DOI: 10.37737/ace.3.4_116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 05/08/2021] [Indexed: 03/21/2024]
Abstract
BACKGROUND Delirium is the most commonly experienced disorder in consultation liaisons. There are currently research and guidelines in Japan for delirium treatment. Still, there is no retrospective observational study of consultation-liaison psychiatry (CLP) and antipsychotic-centered drugs. This study aims to examine CLP's effectiveness and drug treatment. METHODS Using a Japanese national inpatient database of 2016 and 2017, we investigated the presence or absence of CLP for the treatment of delirium in postoperative delirium patients, the status of drug selection, delirium days, and the average days from surgery to discharge. We examined factors affecting days from surgery to discharge using multiple linear regression analysis. RESULTS This study was classified into a CLP group (n = 1,142) and a non-CLP group (n = 11,355). The days from surgery to discharge in the CLP and non-CLP groups was 16.7 and 17.1, respectively (p = 0.3613). There was a significant difference in the delirium days between the CLP and non-CLP groups (8.9 vs. 7.4; p < 0.00001). Haloperidol infusion was frequently used between the days from surgery to first day of delirium. It was prescribed less often than other oral drugs. Multiple regression analysis identified an association between age, men, CCI1-2, CCI ≥3, number of drugs used, days from surgery to first day of delirium, and early CLP (0-2days) with days from surgery to discharge. CONCLUSIONS We investigated the effectiveness of CLP and the actual conditions of pharmacotherapy for postoperative delirium. Our findings suggest that early CLP may be associated with shorter days from surgery to discharge.
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Affiliation(s)
- Yuki Noda
- Department of Health Administration and Policy, Tohoku University
| | - Kunio Tarasawa
- Department of Health Administration and Policy, Tohoku University
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School
| | - Kenji Fujimori
- Department of Health Administration and Policy, Tohoku University
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Bilotta F, Weiss B, Neuner B, Kramer S, Aldecoa C, Bettelli G, Sanders RD, Delp SM, Spies CD. Routine management of postoperative delirium outside the ICU: Results of an international survey among anaesthesiologists. Acta Anaesthesiol Scand 2020; 64:494-500. [PMID: 31883373 DOI: 10.1111/aas.13535] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 11/18/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative delirium (POD) is a severe brain dysfunction. Although data indicate a high relevance, no survey has investigated the routine practice to monitor delirium outside the ICU setting after surgery. Prior to publishing of the new European Society of Anaesthesiology (ESA) guidelines on POD, an international survey was conducted to assess current practice. METHODS European Society of Anaesthesiology-endorsed online survey; Trial Registration: NCT-identifier: 02513537. RESULTS In total, 566 respondents from 62 countries accessed, and 564 (99.6%) completed the survey (completion rate). Overall, 385 (68%) of the respondents reported that delirium is either "very relevant" or "relevant" for their daily clinical practice. In all, 38 (7%) of the respondents routinely monitor for delirium in >50% of all patients. Asked on the monitoring time point, more than half (n = 308, 55%) indicated to screen before or at recovery room discharge, 235 (42%) up to the first postoperative day, 143 (25%) up to 3 days, and 77 (14%) up to 5 postoperative days. Although there is a lack of long-term monitoring, nearly all respondents (n = 530, 94%) reported to treat delirium. Availability of EEG/EMG-based monitoring to assess the depth of anaesthesia was high in the study group (n = 547, 97%) and was used by more than one-third of the respondents to reduce risk of burst suppression (n = 189, 34%). CONCLUSION Although delirium is perceived as a relevant condition among anaesthesiologists, there is a high demand for implementing monitoring strategies after publishing of the POD Guideline. The survey shows that tools necessary for POD Guideline implementation are available in the centres represented by the respondents.
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Affiliation(s)
- Federico Bilotta
- Department of Anesthesiology Critical Care and Pain Medicine, "Sapienza" University of Rome Rome Italy
| | - Bjoern Weiss
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Bruno Neuner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Sylvia Kramer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - César Aldecoa
- Department of Anaesthesiology & Intensive Care Hospital Universitario Rio Hortega Valladolid Spain
| | - Gabriella Bettelli
- Department of Geriatric Surgery Italian National Research Centres on Aging/IRCCS Ancona Italy
- Department of Anaesthesia, Analgesia and Intensive Care Italian National Research Centres on Aging/IRCCS Ancona Italy
| | | | - Simon M. Delp
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Claudia D. Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK) Charité – Universitätsmedizin Berlin corporate member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
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Abstract
BACKGROUND There is little expert consensus as to which drugs should comprise the first-line pharmacological treatment for delirium. We sought to assess experts' opinions on the first-line oral and injection drugs for delirium associated with a diverse range of clinical features using a rating-based conjoint analysis. METHODS We conducted a cross-sectional study. We mailed a questionnaire to all consultation-liaison psychiatrists/educators certified by the Japanese Society of General Hospital Psychiatry. RESULTS Of 136 experts (response rate: 27.5%), more than 68% recommended the use of risperidone or quetiapine administered orally for hyperactive delirium, except in patients with comorbid diabetes and renal dysfunction. More than 67% recommended the use of haloperidol administered intravenously for hyperactive delirium if an intravenous line has been placed. No oral or injection drugs were recommended by over half of experts for treatment of hypoactive delirium with any clinical features. CONCLUSIONS In the absence of a definitive treatment trial, there are both areas of agreement and a lack of consensus regarding the first-line drug. Efforts are needed to routinely collect information that would allow a comparison of the effectiveness and safety of various drugs in real-world clinical practice.
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The pharmacokinetics of mianserin suppositories for rectal administration in dogs and healthy volunteers: a pilot study. J Pharm Health Care Sci 2016; 2:12. [PMID: 27190632 PMCID: PMC4869351 DOI: 10.1186/s40780-016-0046-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 04/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We formulated mianserin suppositories for the treatment of delirium and evaluated their pharmacokinetics by measuring plasma drug concentrations in dogs and healthy human volunteers. METHODS Mianserin suppositories were prepared by a melting technique using Tetramide® tablets and Witepsol H-15 as the suppository base. Pharmacokinetics of this 30-mg mianserin preparation were evaluated in three beagle dogs and three healthy adult males, in line with ethics committee approval. Plasma mianserin levels were determined using gas chromatography-mass spectrometry. RESULTS In dogs, the maximum plasma mianserin concentration (Cmax) was 1.3 ± 0.4 ng/mL, the time to Cmax (tmax) was 5.5 ± 4.3 h, and the area under the plasma concentration-time curve from 0 to 24 h (AUC0-24) was 18.9 ± 1.9 h・ng/mL. In humans, the Cmax was 14.6 ± 6.3 ng/mL, the tmax was 8 h, and the AUC0-24 was 266 ± 103 h・ng/mL. CONCLUSIONS The current study characterized the pharmacokinetics of mianserin suppositories in dogs and humans. As compared to oral administration, the suppositories produced a lower Cmax and a delayed tmax, although AUC0-24 values were comparable. It will be necessary to identify an appropriate dose that produces an adequate plasma mianserin concentration for effective and safe clinical use. TRIAL REGISTRATION UMIN000013853.
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Horacek R, Krnacova B, Prasko J, Latalova K. Delirium as a complication of the surgical intensive care. Neuropsychiatr Dis Treat 2016; 12:2425-2434. [PMID: 27703360 PMCID: PMC5036558 DOI: 10.2147/ndt.s115800] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The aim of this study was to examine the impact of somatic illnesses, electrolyte imbalance, red blood cell count, hypotension, and antipsychotic and opioid treatment on the duration of delirium in Central Intensive Care Unit for Surgery. PATIENTS AND METHODS Patients who were admitted to the Department of Central Intensive Care Unit for Surgery in the University Hospital Olomouc from February 2004 to November 2008 were evaluated using Riker sedation-agitation scale. Their blood pressure, heart rate, respiratory rate, and peripheral blood oxygen saturation were measured continually, and body temperature was monitored once in an hour. The laboratory blood tests including sodium, potassium, chlorides, phosphorus, urea and creatinine, hemoglobin, hematocrit, red and white blood cell count, and C-reactive protein, albumin levels and laboratory markers of renal and liver dysfunction were done every day. All measurements were made at least for ten consecutive days or longer until the delirium resolved. RESULTS The sample consisted of 140 consecutive delirious patients with a mean age of 68.21±12.07 years. Delirium was diagnosed in 140 of 5,642 patients (2.48%) admitted in CICUS in the last 5 years. The median duration of delirium was 48 hours with a range of 12-240 hours. Statistical analysis showed that hyperactive subtype of delirium and treatment with antipsychotics were associated with prolonged delirium duration (hyperactive 76.15±40.53 hours, hypoactive 54.46±28.44 hours, mixed 61.22±37.86 hours; Kruskal-Wallis test: 8.022; P<0.05). The duration of delirium was significantly correlated also with blood potassium levels (Pearson's r=0.2189, P<0.05), hypotension (hypotension 40.41±30.23 hours versus normotension 70.47±54.98 hours; Mann-Whitney U=1,512; P<0.05), administration of antipsychotics compared to other drugs (antipsychotics 72.83±40.6, benzodiazepines 42.00±20.78, others drugs, mostly piracetam 46.96±18.42 hours; Kruskal-Wallis test: 17.39, P<0.0005), and history of alcohol abuse (with a history of abuse 73.63±45.20 hours, without a history of abuse 59.54±30.61 hours; Mann-Whitney U=1,840; P<0.05). One patient had suffered from complicated postoperative hypostatic pneumonia and died due to respiratory failure (patient with hypoactive subtype). According to the backward stepwise multiple regression, the best significant predictors of duration of the delirium were the hypotension, type of psychopharmacs, type of delirium, the daily dose of opioids, a combination of psychopharmacs, history of alcohol abuse, plasma level of potassium, anemia, hyperpyrexia, and plasma level of albumin, reaching statistical significance (analysis of variance: F=5.205; df=24; P<0.005; adjusted r2=0.637). CONCLUSION The hyperactive type of delirium, hypotension, usage of antipsychotics, the higher daily dose of opioids, a combination of psychopharmacs, history of alcohol abuse, low blood levels of potassium, anemia, hyperpyrexia, and hypoalbuminemia in the CICUS were associated with longer duration of delirium.
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Affiliation(s)
| | - Barbora Krnacova
- Department of Psychiatry, Faculty of Medicine and Dentistry, University Hospital Olomouc, Palacky University Olomouc, Czech Republic
| | - Jan Prasko
- Department of Psychiatry, Faculty of Medicine and Dentistry, University Hospital Olomouc, Palacky University Olomouc, Czech Republic
| | - Klara Latalova
- Department of Psychiatry, Faculty of Medicine and Dentistry, University Hospital Olomouc, Palacky University Olomouc, Czech Republic
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Rooney S, Qadir M, Adamis D, McCarthy G. Diagnostic and treatment practices of delirium in a general hospital. Aging Clin Exp Res 2014; 26:625-33. [PMID: 24789220 DOI: 10.1007/s40520-014-0227-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 04/08/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite the increase in research on delirium, it remains underdiagnosed and difficult to manage, and the outcome is poor especially in older people. AIMS To identify the clinically diagnosed rates of delirium, the possible aetiologies, to describe treatment, number and type of psychotropic medication used and to investigate the reasons for referral to a liaison psychiatric team. METHODS Retrospective study of medical records of inpatients admitted to Sligo Regional Hospital during an 18-month period. RESULTS One hundred and fifty-six files had a documentation of delirium (time prevalence 2%). Mean age of the sample was 82 years (SD = 7.2), 66 (42%) were male. Sixty-nine (44.2%) of the total sample had a previous history of dementia, and 57 (36.5%) had a previous history of delirium. In 67 (43.2%) samples, the cause was infection, while in 4, no specific cause was identified. Ninety (58%) were referred to the liaison service, but only in 26 (28.9 %), the reason for referral was "acute confusion" or "delirium". In a majority of referrals, the reason was an affective disorder more often depression. There were no significant differences between delirium subtypes and referrals (χ(2) = 3.868, df 3, p = 0.28). Examination of the amount of antipsychotics prescribed before, during and after delirium shows that there was a significant increase in use during the delirium (χ(2) = 17.512, df 8, p = 0.025) and decrease in z-hypnotics medication (zopiclone/zolpidem), (χ(2) = 20.114, df 4, p < 0.001), while benzodiazepines and antidepressants remained the same. CONCLUSIONS Delirium is often misdiagnosed and unrecognized in hospital settings; however, when identified the pharmacological management is appropriate.
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Affiliation(s)
- Siobhan Rooney
- Medical Education, Sligo Medical Academy, NUI Galway, Galway, Ireland,
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von Haken R, Gruss M, Plaschke K, Scholz M, Engelhardt R, Brobeil A, Martin E, Weigand MA. [Delirium in the intensive care unit]. Anaesthesist 2010; 59:235-47. [PMID: 20127059 DOI: 10.1007/s00101-009-1664-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
In recent years delirium in the intensive care unit (ICU) has internationally become a matter of rising concern for intensive care physicians. Due to the design of highly sophisticated ventilators the practice of deep sedation is nowadays mostly obsolete. To assess a ventilated ICU patient for delirium easy to handle bedside tests have been developed which permit a psychiatric scoring. The significance of ICU delirium is equivalent to organ failure and has been proven to be an independent prognostic factor for mortality and length of ICU and hospital stay. The pathophysiology and risk factors of ICU delirium are still insufficiently understood in detail. A certain constellation of pre-existing patient-related conditions, the current diagnosis and surgical procedure and administered medication entail a higher risk for the occurrence of ICU delirium. A favored hypothesis is that an imbalance of the neurotransmitters acetylcholine and dopamine serotonin results in an unpredictable neurotransmission. Currently, the administration of neuroleptics, enforced physiotherapy, re-orientation measures and appropriate pain treatment are the basis of the therapeutic approach.
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Affiliation(s)
- R von Haken
- Klinik für Anaesthesiologie, Ruprecht-Karls-Universität Heidelberg, Deutschland.
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Seitz DP, Gill SS. Neuroleptic malignant syndrome complicating antipsychotic treatment of delirium or agitation in medical and surgical patients: case reports and a review of the literature. PSYCHOSOMATICS 2009; 50:8-15. [PMID: 19213967 DOI: 10.1176/appi.psy.50.1.8] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Neuroleptic malignant syndrome (NMS) is a potentially fatal adverse event associated with the use of antipsychotics. OBJECTIVE The authors provide information on the development and outcome of NMS during antipsychotic treatment of delirium or agitation in medically ill patients. METHOD The authors present case reports and a literature review of NMS arising during antipsychotic treatment of delirium. RESULTS A total of 25 cases of NMS occurring in patients with delirium or agitation were identified. Most cases involved men with agitated delirium who received relatively high doses of parenteral haloperidol. The signs and symptoms of NMS episodes were similar to those reported in other settings, and most patients had a complete recovery. CONCLUSION Clinicians utilizing antipsychotics in managing delirium or agitation are advised to be vigilant for NMS. Further study is required to determine whether certain patient characteristics or medications present greater risk for this serious adverse event.
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Affiliation(s)
- Dallas P Seitz
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada.
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Bourne RS, Tahir TA, Borthwick M, Sampson EL. Drug treatment of delirium: past, present and future. J Psychosom Res 2008; 65:273-82. [PMID: 18707951 DOI: 10.1016/j.jpsychores.2008.05.025] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Revised: 04/23/2008] [Accepted: 05/15/2008] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this review was to summarize and critically evaluate the current literature regarding the safety and efficacy of drug therapy in delirium. We also identified recent research developments and highlighted some ongoing clinical trials to explore future directions in drug treatment and prevention of delirium. METHODS We conducted a literature search of Medline, Embase, PsychInfo, and Cochrane Review databases, which included both prospective and retrospective clinical trials and case studies on delirium and drug therapy in adult patients up to March 2008. Abstracts from recent topical conferences were also reviewed. Ongoing delirium drug studies were identified via the WHO International Clinical Trials Registry Platform Search Portal, accessed March 12, 2008. RESULTS The evidence base for effective drug treatment of delirium is restricted by limitations in many of the studies conducted to date. However, there has been an increase in the quantity and quality of delirium drug studies in recent years; preliminary reports and ongoing studies add to this trend. Although efficacy rates between typical and atypical antipsychotic agents are similar, the latter are associated with fewer extrapyramidal side effects. Prophylactic interventions with antipsychotic and cholinesterase inhibitors in high-risk patients provide an opportunity to improve postoperative patient care. Alternative techniques and medication opportunities could be explored in attempts to minimize drug induced delirium potential. CONCLUSIONS Appropriate drug therapy should be considered part of systematic approaches to delirium treatment and prevention. There is a need for well-designed randomized, double-blind placebo-controlled trials investigating the drug management of various aspects of delirium, including delineating treatment by delirium subtype, dose ranging studies, and optimal duration of therapy.
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Affiliation(s)
- Richard S Bourne
- Department of Critical Care, Sheffield Teaching Hospitals, Sheffield, United Kingdom.
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Abstract
BACKGROUND Delirium is now the preferred term to describe acute confusional states. It is experienced by 10 to 30% of all hospital inpatients. Delirium is potentially reversible and is related to several adverse outcomes, including increased hospital length of stay, poor functional status, persistent cognitive impairment, need for institutional care and probably mortality. Disruption of the cholinergic system has been proposed as a key mechanism of delirium. Cholinesterase inhibitors enhance the cholinergic system and there have been reports that they might be beneficial in treating delirium. OBJECTIVES To assess the efficacy and safety of cholinesterase inhibitors in the treatment of delirium. SEARCH STRATEGY The Cochrane Dementia and Cognitive Improvement Group's Register of Clinical Trials (which includes records from MEDLINE, EMBASE, PsycINFO, CINAHL, CENTRAL, LILACS and other databases) was searched for relevant randomised controlled trials using the terms: donepezil or aricept, galantamine or reminyl, rivastigmine OR exelon and tacrine OR cognex on 19 April 2005. As this Specialised Register only contains trials relating to dementia and cognitive impairment, in addition all years of MEDLINE, EMBASE, PsycINFO and CINAHL were searched for trials of cholinesterase inhibitors for delirium in non-demented people. SELECTION CRITERIA Unconfounded, blinded randomised controlled trials, published or unpublished in which treatment with cholinesterase inhibitors was administered and compared with alternative interventions in patients with delirium are included. DATA COLLECTION AND ANALYSIS Two reviewers (RO, SK) independently assessed the quality of the studies according to parameters such as randomisation, blinding and how dropouts were managed. Each cholinesterase inhibitor was to be examined separately and together as a group. The primary outcome measures of interest are length of delirium, severity of delirium and presence and severity of behavioural symptoms (e.g. agitation and hallucinations). Other outcomes of interest include: cognition, need for institutionalisation, length of hospital admission and adverse effects. MAIN RESULTS There was one included trial of donepezil compared with placebo in 15 patients. No significant difference between the treatment and placebo groups was found in the duration of delirium. The mean duration of postoperative delirium for the donepezil group was 1.0 day (Standard Error 0.0) while for the placebo group it was 1.3 days (Standard Error 0.19). No other outcomes were measured for the patients who developed delirium. AUTHORS' CONCLUSIONS There is currently no evidence from controlled trials that donepezil is effective in the treatment of delirium. Further trials using cholinesterase inhibitors for the treatment of delirium are needed.
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Affiliation(s)
- R Overshott
- 2nd Floor Education and Research Centre, Old Age Psychiatry Department, Wythenshawe Hospital, Souhmoor Road, Wythenshawe,Manchester, UK, M23 9LT.
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Miyaji S, Yamamoto K, Hoshino S, Yamamoto H, Sakai Y, Miyaoka H. Comparison of the risk of adverse events between risperidone and haloperidol in delirium patients. Psychiatry Clin Neurosci 2007; 61:275-82. [PMID: 17472596 DOI: 10.1111/j.1440-1819.2007.01655.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of this study was to determine the risk of adverse events for risperidone and haloperidol in delirium patients. The authors conducted a retrospective study with medical records of 266 Japanese delirium inpatients who were referred to them between July 2001 and May 2005. Information on gender, age, delirium, drug therapy, adverse events, death, and other relevant factors was collected and analyzed for each patient. As a primary antipsychotic drug for the treatment of delirium, risperidone was used in 93 patients; oral haloperidol was used in 95; and intravenous or intramuscular haloperidol was used in 61. The incidence of adverse events was 6.5% for risperidone, 31.4% for oral haloperidol, and 32.8% for haloperidol injection. The incidence of death during delirium was 3.2% for risperidone, 2.1% for oral haloperidol, and 13.1% for haloperidol injection. The incidence of death within 1 year after the onset of delirium was 30.1% for risperidone, 29.5% for oral haloperidol, and 45.9% for haloperidol injection. Between risperidone, oral haloperidol, and intravenous or intramuscular haloperidol the incidence of adverse events was significantly lowest for risperidone, and the incidence of death during delirium was significantly highest for intravenous or intramuscular haloperidol. The use of haloperidol as a first-line drug in delirium patients who can receive the drug orally will not contribute to the establishment of drug therapy for delirium based on risk-benefit assessment of the therapy.
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Affiliation(s)
- Shingo Miyaji
- Department of Psychiatry, Kitasato University School of Medicine, Kanagawa, Japan
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Boettger S, Breitbart W. Atypical antipsychotics in the management of delirium: a review of the empirical literature. Palliat Support Care 2006; 3:227-37. [PMID: 16594462 DOI: 10.1017/s1478951505050352] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To review the existing literature of atypical antipsychotics in the treatment of delirium and make recommendations regarding their use in the treatment of delirium. METHODS I conducted a literature search in Pubmed, Psychlit, and Embase for studies using atypical antipsychotics in the treatment of delirium. In the absence of studies, case reports were used. RESULTS Overall 13 studies examined the use of risperidone, olanzapine, and quetiapine, two cases were reported about ziprasidone, and no publication was found using aripiprazole in the treatment of delirium. Among the existing studies were retrospective and prospective, open label studies in addition to one with a double blind design using risperidone. Risperidone, olanzapine, and quetiapine may be all similarly effective in the treatment of delirium, whereas there may be limited efficacy in the use of olanzapine in the hypoactive subtype of delirium in elderly populations, which may generalize to the other atypical antipsychotics. The use of atypical antipsychotics in the treatment of delirium is safe and carries a low burden of side effects. SIGNIFICANCE OF RESULTS Although atypical antipsychotics are widely used in the treatment of delirium, well-designed studies do not exist. Among the existing studies, stronger data supports the use of risperidone and olanzapine, and also quetiapine may be considered in the treatment of delirium. Recommendations are made based on the existing data and literature. The need for well-designed studies to validate the use of atypical antipsychotics in the treatment of delirium continues.
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Affiliation(s)
- Soenke Boettger
- Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, Box 421, New York, New York 10021, USA.
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Kim JY, Jung IK, Han C, Cho SH, Kim L, Kim SH, Lee BH, Lee HJ, Kim YK. Antipsychotics and dopamine transporter gene polymorphisms in delirium patients. Psychiatry Clin Neurosci 2005; 59:183-8. [PMID: 15823165 DOI: 10.1111/j.1440-1819.2005.01355.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The main objective of the present study was to determine the relationship between treatment responses of delirium and genetic polymorphisms in the dopamine transporter. The optimal dosages of haloperidol and risperidone in the treatment of delirium were also investigated. Either haloperidol or risperidone was administered to delirium patients, and delirium symptoms were measured daily until remission. Variable number of tandem repeat (VNTR) polymorphisms of the dopamine transporter were determined using the polymerase chain reaction. Among 42 subjects, symptoms of delirium appeared a mean of 9.68 days after hospitalization. A majority of the subjects (83.3%) had the type 10/10 polymorphism. Dosages of haloperidol and risperidone at the day of recovery were 1.67 mg/day (SD = 1.32; range 0.5-2.5 mg/day) and 1.19 mg/day (SD = 1.14; range 0.5-5.0 mg/day), respectively. The mean drug response time was 8.5 days in the haloperidol group and 4.8 days in the risperidone group (no significant difference). The response rates at the 3rd and 7th days after medication did not differ with either the drug group or the dopamine transporter polymorphism. Relatively low doses of risperidone and haloperidol exhibited similar efficacies, and dopamine transporter polymorphisms do not appear to play a major role in the action of antipsychotics on delirium.
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Affiliation(s)
- Jee-Yeon Kim
- Department of Psychiatry, College of Medicine, Korea University, Ansan Hospital, 516 Gojan-dong, Ansan City, Kyunggi Province 425-707, South Korea
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Ely EW, Stephens RK, Jackson JC, Thomason JWW, Truman B, Gordon S, Dittus RS, Bernard GR. Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: A survey of 912 healthcare professionals*. Crit Care Med 2004; 32:106-12. [PMID: 14707567 DOI: 10.1097/01.ccm.0000098033.94737.84] [Citation(s) in RCA: 250] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Recently published clinical practice guidelines of the Society of Critical Care Medicine recommend monitoring for the presence of delirium in all mechanically ventilated patients because of the potential for adverse outcomes associated with this comorbidity, yet little is known about healthcare professionals' opinions regarding intensive care unit delirium or how they manage this organ dysfunction. The aim of this survey was to assess the medical community's beliefs and practices regarding delirium in the intensive care unit. DESIGN Survey administration was conducted both without a delirium definition (phase 1) and then with a definition of delirium (phase 2). SETTING Critical care meetings and continuing medical education/board review courses from October 2001 to July 2002. PARTICIPANTS A convenience sample of physicians (n = 753), nurses (n = 113), pharmacists (n = 13), physician assistants (n = 12), respiratory care practitioners (n = 8), and others (n = 13). INTERVENTIONS Survey. MEASUREMENTS AND MAIN RESULTS Participants completed 912 of the surveys. The majority (68%) of respondents thought that >25% of adult mechanically ventilated patients experience delirium. Delirium was considered a significant or very serious problem in the intensive care unit by 92% of healthcare professionals, yet underdiagnosis was acknowledged by 78%. Only 40% reported routinely screening for delirium, and only 16% indicated using a specific tool for delirium assessment. Delirium was considered important in the outcome of elderly and young patients by 89% and 60% of the respondents, respectively (p <.0001). The most serious complications these professionals associated with delirium were prolonged mechanical ventilation, self-injury, and respiratory difficulties. Delirium was treated with haloperidol by 66% of the respondents, with lorazepam by 12%, and with atypical antipsychotics by <5%. More than 55% administered haloperidol and lorazepam at daily doses of < or =10 mg, but some used >50 mg/day of either medication. CONCLUSIONS Most healthcare professionals consider delirium in the intensive care unit a common and serious problem, although few actually monitor for this condition and most admit that it is underdiagnosed. Data from this survey point to a disconnect between the perceived significance of delirium in the intensive care unit and current practices of monitoring and treatment.
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Affiliation(s)
- E Wesley Ely
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
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Abstract
Delirium has been recognized for the last 3 millennia and is the most common complication found in hospitalized patients aged 65 and older in the United States. However, critical basic science and clinical research did not progress until the DSM III criteria clearly defined delirium 20 years ago. The term delirium then replaced many nonspecific entities, such as acute confusion state, acute brain syndrome, metabolic encephalopathy, and toxic psychosis. This review discusses the epidemiology, risk factors, interventions, causes, management, and outcomes of delirium. The pathophysiology of delirium has the potential to radically alter our management of delirium and is a controversial area of research.
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Affiliation(s)
- Vivyenne Roche
- University of Texas Southwestern Medical Center, The Mildred Wyatt and Ivor P. Wold Center for Geriatric Care, Department of Internal Medicine, Dallas, Texas 75390-8889, USA.
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Abstract
The mainstay of the pharmacologic management of delirium remains typical antipsychotics, primarily haloperidol. Typical antipsychotics are associated with significant side effects, particularly in the elderly. This article reviews the literature on the use of both typical and atypical antipsychotics in the management of acute delirium, with a focus on the elderly. In this population, typical antipsychotics are associated with substantially more drug induce side effects--either extrapyramidal side effects or anticholinergic effects from the antipsychotics alone or in combination with benztropine or trihexyphenidyl. Anticholinergic toxicity is especially problematic in delirious, demented patients, because most dementias are associated with pre-existing deficiencies in cholinergic neurotransmission. These issues will be reviewed for typical antipsychotics as well as the emerging literature on the use of atypical antipsychotics-- risperidone, olanzapine, and quetiapine--for pharmacologic management of acute delirium. Data from two studies conducted at the Wesley Woods Center at Emory University will be briefly reviewed as they constitute the largest series to date investigating the pharmacologic management of delirious demented patients.
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Affiliation(s)
- Larry Tune
- Department of Psychiatry, Emory University School of Medicine, Wesley Woods Geriatric Center, 1841 Clifton Street, NE, Atlanta, GA, 30329, USA.
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Kim KS, Pae CU, Chae JH, Bahk WM, Jun T. An open pilot trial of olanzapine for delirium in the Korean population. Psychiatry Clin Neurosci 2001; 55:515-9. [PMID: 11555348 DOI: 10.1046/j.1440-1819.2001.00898.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study was performed to assess the efficacy and safety of olanzapine for the treatment of delirium in a Korean population. An open trial of olanzapine was conducted in Korean patients with delirium caused by multiple medicosurgical conditions. All subjects were evaluated by Delirium Rating Scale (DRS), which is known to be one of the most sensitive scales for delirium. In addition, other data for profiles of side-effects were collected and analyzed. Twenty patients were treated by olanzapine with doses of 5.9 +/- 1.5 mg/day. The initial dose was 4.6 +/- 0.9 mg/day and maximal dose of olanzapine was 8.8 +/- 2.2 mg/day. The average duration of treatment was 6.6 +/- 1.7 days and the day of maximal response was 3.8 +/- 1.7 treated days. The scores of DRS were significantly improved from 20.0 +/- 3.6 at the time of pretreatment to 9.3 +/- 4.6 at the post-treatment. All subjects showed no definite serious side-effects including anticholinergic and extrapyramidal symptoms. Olanzapine treatment for patients with delirium was effective and safe. This newer drug may be a useful alternative agent to classical antipsychotics in the treatment of delirium.
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Affiliation(s)
- K S Kim
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
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