Ramelteon for the treatment of delirium in elderly patients: a consecutive case series study

Risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium in elderly patients

Delirium is an acute reversible neuropsychiatric syndrome caused by multiple factors. It is associated with many adverse clinical outcomes including cognitive impairment, functional decline, prolonged hospitalization, and increased nursing service. The prevalence of delirium was high in department of cardiology, geriatric, and intensive care unit of hospital. With the increase in the aged population, further increases in delirium seem likely. However, it remains poorly recognized in the clinical practice. This article comprehensively discusses the latest research perspectives on the epidemiological data, risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium, including specific measures to manage delirium in clinical real-world situations. This article helps readers improve their knowledge and understanding of delirium and helps clinicians quickly identify and implement timely therapeutic measures to address various delirium subtypes that occur in the clinical settings to ensure patients are treated as aggressively as possible.

Melatonin and Ramelteon for the treatment of delirium: A systematic review and meta-analysis

OBJECTIVE

To assess the efficacy of melatonin and melatonergic agonist for the treatment of delirium in hospitalized patients.

METHODS

Embase, MEDLINE, PsycINFO, PubMed, CENTRAL, Cochrane Database of Systematic Reviews, TRIP Medical Database, ClinicalTrials.gov and Google were searched from inception to October 2022. Randomized controlled trials (RCT) and observational studies with any type of comparator evaluating melatonin or melatonergic agonist (ramelteon) enrolling any populations (ICU, surgery, geriatric) were included. Two reviewers independently selected and extracted data using the Cochrane risk of bias tools (RoB2 and ROBINSI).

RESULTS

Out of the 650 screened publications, three RCTs and six observational studies were included (n = 1211). All three RCTs compared melatonin to placebo, as the majority of observational studies compared melatonin or ramelteon to antipsychotics. Two RCTs reported the duration of delirium and a meta-analysis provided a statistical difference between melatonin and placebo (-1.72 days, 95% CI -2.66 to -0.77, p = 0.0004). Five observational studies reported the duration of delirium but only one reported a statistical reduction in the duration of delirium.

CONCLUSION

Although melatonin and ramelteon may be effective treatments for delirium, particularly to shorten the duration of delirium and to limit the use of rescue medication, current data is limited in number and in its quality. Clinicians should wait until higher quality data from ongoing RCTs are available before prescribing melatonin to delirious patients.

Ramelteon in the Treatment of Delirium: New Perspectives from Reported Findings and a Case Observation

:

Ramelteon is a melatonin receptor agonist that is approved for the treatment of insomnia. It is widely used due to its relatively benign side effect profile and lack of dependence or withdrawal. Due to its tolerability, clinicians have attempted to utilize ramelteon to normalize the sleep/wake patterns in patients with delirium as a safer alternative to antipsychotics or other medications. We present the case of a 75-year-old man with long-standing dementia who was hospitalized due to mental status changes, agitation, and sleep disturbance. After addressing possible underlying causes with minimal improvement, the team initiated treatment with ramelteon (8mg nightly) which resulted in rapid improvement of symptoms. Uses and mechanisms of action of ramelteon will be reviewed, as well as current pharmacologic treatments of delirium. Prior research studies and case reports regarding the use of ramelteon in the treatment of delirium will be discussed and suggestions made regarding possible areas of future study.

Effect of Administration of Ramelteon, a Melatonin Receptor Agonist, on the Duration of Stay in the ICU: A Single-Center Randomized Placebo-Controlled Trial

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Objectives:

Occurrence of delirium in the ICU is associated with a longer stay in the ICU. To examine whether the use of ramelteon, a melatonin agonist, can prevent delirium and shorten the duration of ICU stay of critically ill patients.

Design:

A single-center, triple-blinded, randomized placebo-controlled trial.

Setting:

ICU of an academic hospital.

Patients:

Eligible patients were ICU patients who could take medicines orally or through a nasogastric tube during the first 48 hours of admission.

Interventions:

The intervention group received ramelteon (8 mg/d), and the control group received placebo (1 g/d of lactose powder) at 20:00 hours every day until discharge from the ICU.

Measurements and Main Results:

A total of 88 subjects were randomized to the ramelteon group (45 subjects) or the placebo group (43 subjects). As the primary endpoint, there was a trend toward decrease in the duration of ICU stay (4.56 d) in the ramelteon group compared with the placebo group (5.86 d) (p = 0.082 and p = 0.028 before and after adjustments). As the secondary endpoints, statistically significant decreases in the occurrence rate (24.4% vs 46.5%; p = 0.044) and duration (0.78 vs 1.40 d; p = 0.048) of delirium were observed in the ramelteon group. The nonintubated patients of the ramelteon group showed statistically significantly fewer awakenings per night and a higher proportion of nights without awakenings.

Conclusions:

Ramelteon tended to decrease the duration of ICU stay as well as decreased the occurrence rate and duration of delirium statistically significantly.

Melatonin and the Prevention and Management of Delirium: A Scoping Study

Background

The therapeutic benefit of melatonin in the prevention and treatment of delirium is uncertain.

Objective

To perform a scoping study to describe the existing literature regarding the use of melatonin and ramelteon in the prevention and treatment of delirium.

Methods

We performed a scoping study using the Arksey and O’Malley framework to explore our objective. Two independent panels searched MEDLINE, OVID, EMBASE, PubMed, Google Scholar, and Cochrane Library for relevant articles up to November 2017 describing the use of melatonin and ramelteon in the prevention or management of delirium. We extracted relevant summary data from the studies and attempted to draw conclusion regarding benefit.

Results

We summarized evidence from 20 relevant articles. There were a total of nine articles: five randomized controlled trials (RCTs), two retrospective medical record reviews, one non-randomized observational study, and one case report describing the role of either melatonin or ramelteon in preventing delirium. There were a total of 11 studies studying the role of either melatonin or ramelteon in the management of established delirium. None of these were RCT and were predominantly case series and case reports. Four of the five trials studying the effect of melatonin analogs in preventing delirium reported a beneficial effect but study heterogeneity limited any broad recommendations. Similarly, the lack of any well-designed trials limits any recommendations regarding the effect of melatonin analogs in treating delirium.

Conclusion

Large, well-designed clinical trials are required to explore the potential beneficial effects of melatonin and ramelteon on delirium prevention and management.

Melatonin Receptor Agonists for Delirium Prevention

OBJECTIVE

To review the prospective controlled trials available for the use of melatonin receptor agonists for delirium prevention.

DATA SOURCES

A MEDLINE literature search (1946 to July 2016) was conducted using the search terms delirium, melatonin, ramelteon, tryptophan, and melatonin-receptor agonist. Prospective controlled clinical trials with delirium prevention as an outcome were included. The references of identified articles were reviewed to identify other relevant articles.

STUDY SELECTION AND DATA EXTRACTION

Controlled clinical trials in humans, limited to the English language, were reviewed. Five randomized and 1 nonrandomized prospective controlled clinical trial exploring the use of melatonin receptor agonists for delirium prevention were evaluated.

DATA SYNTHESIS

Melatonin agonist therapy for delirium prevention has produced conflicting results in clinical trials. Delirium incidence ranged from no change to significant reductions of approximately 12% to 30%. Four trials were conducted with melatonin as the investigated agent, 1 with l-tryptophan, and 1 with ramelteon. The study setting also varied, with 4 trials being conducted in surgical patients and 2 trials in medical patients. Melatonin provided conflicting results, with 3 trials showing decreased delirium incidence and the largest randomized controlled trial showing no benefit. No benefit was found using l-tryptophan in delirium prevention. The single, small ramelteon trial showed decreased delirium incidence. Safety evaluations during trials were limited. Three trials found adverse effects similar to placebo, whereas the remaining 3 trials did not evaluate adverse effects.

CONCLUSIONS

The routine use of melatonin receptor agonists for delirium prevention cannot be recommended at this time.

Beneficial Effects of Ramelteon on Rapid Eye Movement Sleep Behavior Disorder Associated with Parkinson's Disease - Results of a Multicenter Open Trial

Objective Melatonin is effective for treating patients with rapid eye movement sleep behavior disorder (RBD). Ramelteon, a novel hypnotic, acts as a melatonin receptor agonist. In the current study, we investigated the effects of ramelteon on sleep disorders, including RBD, in patients with Parkinson's disease (PD). Methods We evaluated 35 patients from multiple centers with idiopathic PD accompanied by sleep disturbances (age: 69.1±11.1 years; 17 men, 18 women; PD morbidity: 6.9±5.7 years; Hoehn & Yahr stage: 2.5±0.8; levodopa dose equivalent: 561±401 mg/day). The patients received 8 mg of ramelteon before sleep once daily for 12 weeks. Motor and sleep symptoms were evaluated both before and after ramelteon administration. Results Of the 35 patients enrolled in this study, 24 (68.6%) were diagnosed with probable RBD (pRBD) using the Japanese version of the RBD screening questionnaire. Ramelteon administration reduced the severity of sleep disturbances in patients with PD. It also lowered scores on the Japanese version of the RBD questionnaire in patients with PD and pRBD. Conclusion Ramelteon may have beneficial effects on sleep disturbances, especially on RBD in patients with PD.

Therapeutic effects of melatonin receptor agonists on sleep and comorbid disorders

Several melatonin receptors agonists (ramelteon, prolonged-release melatonin, agomelatine and tasimelteon) have recently become available for the treatment of insomnia, depression and circadian rhythms sleep-wake disorders. The efficacy and safety profiles of these compounds in the treatment of the indicated disorders are reviewed. Accumulating evidence indicates that sleep-wake disorders and co-existing medical conditions are mutually exacerbating. This understanding has now been incorporated into the new Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Therefore, when evaluating the risk/benefit ratio of sleep drugs, it is pertinent to also evaluate their effects on wake and comorbid condition. Beneficial effects of melatonin receptor agonists on comorbid neurological, psychiatric, cardiovascular and metabolic symptomatology beyond sleep regulation are also described. The review underlines the beneficial value of enhancing physiological sleep in comorbid conditions.