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Delirium in older people, systematic screening, prevention and recognition
- Mehraj Shah, Farida Jan, Akeem Sule (24 April 2007)
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Delirium: a common cause of misdiagnosis in the elderly
- Ángel J Romero-Cabrera, Alfredo D. Espinosa-Brito, MD, PhD, Professor (24 April 2007)
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The unsatisfactory coverage of delirium by NICE, the JCHMT and the Royal Colleges of Physicians
- Alasdair MJ MacLullich, John M Starr, A Peter Passmore (27 April 2007)
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Delirium management in the acute setting
- sunku h guptha (27 April 2007)
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Drug treatment of delirium
- David Meagher (28 April 2007)
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Delirium in older people
- Jatinder K Juss, Duncan Forsyth, Consultant Geriatrician, Addenbrookes Hospital, Cambridge University Hospitals NHS Trust , Hills Road, Cambridge, CB2 0QQ (30 April 2007)
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Delirium and emergent EEG
- Leonardo Cocito, Daniela Audenino, Paola Fontana, and Alberto Primavera (7 May 2007)
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Post-operative confusion
- Michael Patkin (18 May 2007)
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Pharmacologic treatment of delirium in older people
- Domingo R Hidalgo, Francesc Formiga, Enric Duaso, Antonia Balet (21 May 2007)
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Mehraj Shah, Staff Grade Psychiatrist Bedfordshire and Luton Mental Health and social care partnership NHS Trust, Farida Jan, Akeem Sule
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Young’s review (1) raises interesting discussions on management of delirium in elderly. He highlights the extent of this treatable and to some extent avoidable condition and points out that health service planners and practitioners are ignoring the situation. While awaiting the government initiatives we believe health care professional can make the difference by using the simple measures based on current clinical knowledge and research in the management of delirium in elderly. In recent years, the emphasis in the approach to delirium has shifted from ad hoc treatment to systematic screening and prevention. The management of delirium in elderly may be improved by aiming at primary preventing, early detection and prompt management. There is growing evidence that incidence of delirium can be reduced in high risk groups in surgical settings. Pre-operative cognitive impairment, as measured by the MMSE or the Clock-Drawing Test, has been found to be an important predictor for postoperative delirium. Jos de Jonghe (2) in the study on patients undergoing hip surgery found that most elderly patients undergoing hip surgery with postoperative delirium already have early symptoms in the prodromal phase of delirium. These findings are potentially useful for screening purposes and for optimizing prevention strategies targeted at reducing the incidence of postoperative delirium. By using low-dose prophylactic haloperidol treatment he found out the incidence of delirium can be reduced. Wong Tin Niam (3) in a study on patients undergoing hip surgery showed that methods proven to prevent delirium can be introduced into routine clinical practice and that this appears to prevent cases of delirium. A recent large retrospective study found that only 4% of patients had a recorded diagnosis of delirium. Yet it is widely recognised that an episode of delirium may occur in up to 56% of hospitalised older people (4). Increasing doctors’ and nurses’ awareness of delirium can be achieved through a brief and inexpensive educational programme. The educational package comprises of a formal presentation and small group discussion written information and guidelines on how to prevent recognise and manage delirium in older people; regular one-to-one and small group discussions during with the aim of enhancing their learning experience with specific examples. The follow-up meetings reinforcing learning and providing an informal in a non-judgemental environment to test knowledge and level of retained information among staff. This educational programme significantly decreases the prevalence of delirium among older inpatients and increases recognition of cases. Such an educational programme can be easily rolled out across hospital units caring for older people (5). Article by TED S. RIGNEY (6) makes similar suggestion that increasing the awareness of the aetiologies and risk factors of delirium should enable nurses to focus on patients at risk and to recognize delirium symptoms early. Knowledge of pharmacological and non-pharmacological treatments for delirium will provide the nurse with an arsenal of potential interventions in the care of the delirious hospitalized elder. The poor understanding of delirium by staff stems from a historically low educational emphasis on delirium in medical and nursing schools. Simply, what is really needed is a change in hospital culture (7). 1.John young, Sharon K Inouye, Delirium in old people. British Medical journal. 2007; 334: 842-6 2. Jos de Jonghe et al Early Symptoms in the Prodromal Phase of Delirium: A Prospective Cohort Study in Elderly Patients Undergoing Hip Surgery.[Article] American Journal of Geriatric Psychiatry. 15(2):112-121, February 2007. 3. Wong Tin Niam et al. Quality project to prevent delirium after hip fracture. Australasian Journal on Ageing. 24(3):174-177, September 2005 4.Kales HC, Kamholz BA, Visnic SG, Blow FC. Recorded delirium in a national sample of elderly inpatients: potential implications for recognition. J Geriatric Psychiatry Neurol 2003; 16: 32–8. 5.NAJI TABET at el An educational intervention can prevent delirium on acute medical wards Age and Ageing 2005; 34: 152–156 6. TED S. RIGNEY ,Delirium in the hospitalized elderly and recommendations for practice.. Geriatric Nursing. 27(3):151-157, May/June 2006. 7.O’Keeffe S. The prevention of delirium. In Lindesay J,Rockwood K, Macdonald A eds. Delirium in Old Age. Oxford: Oxford University Press, 2002. Competing interests: None declared |
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Ángel J Romero-Cabrera, MD, Associate Professor Teaching Hospital, Alfredo D. Espinosa-Brito, MD, PhD, Professor
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Editor: We have read with pleasure the Clinical Review “Delirium in older people” by Young and Inouye (1). Delirium is one of the great geriatric syndromes, very common in the emergency department and hospitalization wards in our “Dr. Gustavo Aldereguía Lima” Teaching Hospital in Cienfuegos, where more than 15% of the population is 60 years and over. Delirium prevalence in hospitalized elderly patients varies from 10 to 15% at admission, and 5 to 40% post-admission. In frail hospitalized elderly patients it is reported near 60% of cases, and it constitutes an episode that enlarges the stay at the hospital and has high complication rates, which are often lethal. (2,3) Many medical doctors misdiagnose and mistreat delirium. At the same time they contribute to increasing its frequency by prescribing drugs that are some of the precipitating and aggravating factors in older persons, in whom cognition is their most vulnerable function. We consider that main causes of diagnoses error are: (4)
Clinical Review by Young and Inouye (1) illustrates the differences between delirium and dementia, and how these two conditions coexist and it is possible that they overlap. Usually dementia is characterized by its insidious onset, long duration, lucid awareness level, normal attention (less in severe cases), relatively stable during 24 hours, absence of hallucinations, and poor reversibility. On the other hand, delirium starts suddenly, it has short length, confused awareness level, incorrect attention, fluctuating during 24 hours, with nocturnal exacerbation, frequent hallucinations, and many times reversible if the underlying cause is removed or ameliorated. All these considerations are better understood by geriatricians. However, elderly patients are attended more and more by specialists of very different branches at hospitals. So, the solution for better care for this increasing group is an approach that includes the education of all medical doctors in the management of common elderly syndromes as delirium is. We welcome that the British Medical Journal, a prestigious general journal, published this review article to share present ideas about this important topic. Old people with acute conditions required quick and precise medical care. Misdiagnosis in delirium carries catastrophic consequences and definitively aggravates the prognosis of the patients, because of not treat or mistreat a potential reversible condition. Ángel J. Romero-Cabrera, MD, Associate professor,
Internal Medicine and Geriatric Department Teaching Hospital “Dr. Gustavo Aldereguía Lima”, Cienfuegos, Cuba References 1. Young J, Inouye SK. Delirium in older people. BMJ 2007;334:842-846 2. Altimir S, Prats M. Síndrome confusional en el anciano. Med Clin (Barc) 2002;119(10):386-389 3. Ribera Casado JM. El síndrome confusional agudo: Un “síndrome geriátrico” en alza. Rev Clin Esp 2005;205(10):469-471 4. Romero-Cabrera AJ. Temas para la asistencia clínica del Adulto Mayor (in press) Competing interests: None declared |
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Alasdair MJ MacLullich, MRC Clinician Scientist Fellow & Honorary Consultant in Geriatric Medicine University of Edinburgh, EH16 4TJ, Scotland, UK, John M Starr, A Peter Passmore
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Despite its prevalence and seriousness, delirium is still underdiagnosed and undertreated. The reasons for this neglect are unclear. However, we suggest that a crucial factor in the UK is the inadequate coverage of delirium in several influential, core general medical curricula and guidelines documents. A current example is the draft guideline from the UK’s National Institute of Clinical Excellence (NICE) on Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital (1). The term delirium does not appear anywhere in its 94 pages. Neither is there any reference to the older diagnostic term acute confusional state (superseded by delirium in ICD-10 and DSM-IV). More broadly, and even allowing for informal terminology, there appears to be no coverage of mental state in the context of acute illness. For example, cognitive assessments are not mentioned anywhere. This is a fundamental omission. Delirium is extremely common, occurring in 11-42% of medical inpatients (2). Delirium is an adverse prognostic sign: altered mental status appears in several prognostic scoring systems, eg. the British Thoracic Society’s CURB-65 used in grading severity of community-acquired pneumonia (3). Non-recognition of delirium has potentially serious consequences, as Young and Inouye state (4). For these and many other reasons, any objective analysis would suggest that it is unthinkable that a doctor or other healthcare professional responsible for the care of acutely ill patients should not have an excellent knowledge of the diagnosis, assessment and prevention of delirium. In addition to being missing from the draft NICE guidance, delirium is absent or scantily covered in several major UK curricula for doctors at junior and specialist levels. The term delirium does not appear in the Joint Committee of Higher Medical Training (JCHMT) generic curriculum for physicians (5), or in the specialty curriculum for specialist in Acute Medicine (6). In the latter document, Causes and management of acute confusional states are only mentioned under the learning objective of Minimising symptoms of distress in the often frightened acutely sick patient. Thus, recognition of altered mental status is only mentioned in the context of minimising distress rather than as a fundamental and essential part of the assessment of acutely ill patients. The term delirium does appear in the 2006 draft document The Physician of Tomorrow: Curriculum for General Internal Medicine (Acute Medicine) published by the Federation of the Royal Colleges of Physicians of the UK (7). However, it is included only as part of the Aggressive/Disturbed Behaviour section, under the knowledge requirement Elucidate the factors that allow prediction of aggressive behaviour: personal history, alcohol and substance misuse, delirium. That the only reference to the term delirium is in the context of aggressive behaviour is potentially misleading, given that a minority of patients (<30%) with delirium display agitation or aggression (8). The document does cover Acute Confusion in the top 20 medical diagnoses section, but unfortunately the term delirium does not appear here. This unclear use of terminology will help to maintain the terminological chaos and diagnostic imprecision which partly underpin the consistently poor rates of delirium recognition. Standards of care of this common, serious, distressing and partly preventable condition clearly need to be improved. We suggest that it should be a basic requisite of training for doctors and other healthcare professionals that they have the knowledge, skills and attitudes to diagnose and manage delirium. This would be greatly facilitated if delirium could be given due prominence in core guidelines and curricula. Furthermore, we suggest that the standard, correct terminology – delirium - is consistently used.
(1) National Institute of Clinical Excellence. Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital (draft). (2007). http://guidance.nice.org.uk/page.aspx?o=421645 Competing interests: None declared |
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sunku h guptha, cosultant physician Edith Cavell Hospital, Peterborough, PE3 9GZ
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Dear Editor Professors Young and Inouye's review on delirium is essential reading to all acute physicians. The article however fails to mention one of the disastrous complications of delirium which is recurrent falls leading to fractures in some patients. Patients with hyperactive delirium that results in restlessness and wandering are particularly prone to this complication. In addition, drug treatment for delirium, even if it is recurrent small doses of Haloperidol will result in a further loss of concentration and balance, drop in postural blood pressures and contribute to the risk of falls. Hip fractures are associated with increased morbidity and mortality even in patients without delirium. The consequences of falls are therefore likely to be more disastrous in patients with delirium and the preliminary focus of medical management in these patients in the acute setting should therefore be directed to prevention of falls. Simple management tactics such as reducing sensroy stimulation by caring for these patients in side-rooms and more importantly a one to one nursing contact with the patient in a calm and reassuring manner, supervised assistance of patients in activities such as toileting along with the use of Haloperidol but under continuos supervision of the nurse is essential in the management of delirium. Doctors responsible for the management of patients with delirium should demand these provisions or esle they could be easily accused of dereliction of their duties especially if their only treatment is Haloperidol which in a confused wandering patient left unsupervised is likely to increase the risk of falls and fractures. Competing interests: None declared |
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David Meagher, Consultant Psychiatrist Limerick, Ireland
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Sir, Young and Inouye (1) provide a timely reminder of the difficulties in detection and management of delirium, which is ultimately characterized by poor outcomes for many patients. The advice around the use of drug interventions, however, seems excessively cautious. Clearly, good nursing care with careful attention to delirium risk factors can have modest preventative effects. However, the authors fail to mention two placebo- controlled studies of pharmacological prophylaxis suggesting that low-dose haloperidol (2,3) can reduce delirium incidence and severity. A pilot study of donepezil versus placebo also indicated strong trends for a beneficial effect on delirium incidence and length of hospital stay (4). It is also important that the randomized controlled trial of proactive geriatrics consultation cited (5) included the combination of non-drug interventions along with low-dose haloperidol where indicated (32% of the treatment group developed delirium and 19% received drug treatment). An important conclusion of this work is the demonstration of the benefits of combined intervention. The authors emphasize the importance of minimizing exposure to potentially deliriogenic drugs in all patients at risk of delirium, but equally it should to be appreciated that many deliriogenic agents can also have an important preventative role if used judiciously – for example, although opiate exposure is a risk factor for developing delirium, uncontrolled pain is associated with a nine-fold increase in delirium incidence (6). Equally, benzodiazepines are recommended first line treatment for delirium due to substance withdrawal or seizures (7). The article advocates extremely limited use of pharmacological interventions suggesting that drug treatment should be reserved for patients who pose a risk to themselves or others. Too often pharmacological treatment is precipitated by behavioural problems (8) even though available evidence (9) suggests that both cognitive and non- cognitive symptoms respond to neuroleptic treatment. Moreover, two studies indicate similar response in hypoactive and hyperactive presentations (10,11) and the poorer outcomes observed in patients with hypoactive presentations may relate to less enthusiastic use of neuroleptics in this population. Although best quality evidence for delirium treatment is lacking, there are 20 prospective studies that can usefully inform practice and these suggest that around two-thirds of patients experience significant clinical improvement with drug treatment (12). Although there are concerns regarding the use of antipsychotic agents in patients with dementia, the usefulness of such agents in the treatment of patients with delirium superimposed upon dementia needs to be considered in the context of the brief duration of exposure involved in delirium treatment (typically days), which contrasts sharply with that often used for behavioural and psychological disturbances in dementia. Recent evidence highlights the contrasting neurobiological disturbances that underpin these disorders with greater disruption of dopaminergic turnover evident in delirium compared to dementia (13) perhaps explaining the apparent greater impact of dopamine blockade in the treatment of delirium. Other work documenting delirium chronology indicates that delirum symptoms frequently casue the serious complications that contribute to poor outcome (14). Other work highlights the underappreciated psychological consequences of delirium with the majority of recovered patients able to recall their episode, especially where it involves psychotic symptoms. These recollections cause considerable distress that many patients still find bothersome at six-month follow up (15). These observations argue for more active management of delirium to minimize these complications and distressing psychotic experiences. Placebo- controlled studies are hampered by difficulties around consent and accounting for multiple medical comorbidities. In the interim, available evidence supports the considered use of neuroleptic agents in patients with a range of presentations. (1) Young J, Inouye SK. Delirium in older people. BMJ 2007;334:842-6. (2) Kalisvaart KJ, de Jonghe JFM, Bogaards MJ, et al. Haloperidol prophylaxis for elderly hip surgery patients at risk for delirium: a randomized, placebo-controlled study. J Am Geriatr Soc 2005;53:1658-66. (3) Kaneko T, Cai J, Ishikura T, Kobayashi M, et al. Prophylactic consecutive administration of haloperidol can reduce the occurrence of postoperative delirium in gastrointestinal surgery. Yonago Acta medica 1999;42:179-184. (4) Sampson EL, Raven PR, Ndhlovu PN, Vallance A, et al (2006). A randomised, double-blind, placebo-controlled trial of donepezil hydrochloride (Aricept) for reducing the incidence of postoperative delirium after elective total hip replacement. Int J Geriatr Psychiatry 2007;22:343-9. (5) Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 2001;49:516-22. (6) Morrison RS, Magaziner J, Gilbert M, Koval KJ, McLaughlin MA, Orosz G, Strauss E, Siu AL. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. 2003;58:76-81. (7) American Psychiatric Association. Practice guidelines for the treatment of patients with delirium. Am J Psychiatry 1999;156 (suppl):1–20. (8) Meagher DJ, O’Hanlon D, O’Mahony E, et al. Use of environmental strategies and psychotropic medication in the management of delirium. Br J Psychiatry 1996;168:512–515. (9) Breitbart W, Marotta R, Platt MM, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry 1996;153:231–237. (10) Platt MM, Breitbart W, Smith M, et al. Efficacy of neuroleptics for hypoactive delirium. JNCN 1994; 6:66 (11) Breitbart W, Tremblay A, Gibson C. An open trial of Olanzapine for the treatment of delirium in hospitalised cancer patients. Psychosomatics 2002;43:175-182. (12) Trzepacz PT, Meagher DJ. Delirium. Textbook of Neuropsychiatry (fifth Edition). Eds Yudofsky S, Hales R. American Psychiatric Press, 2007. (13) Van der Cammen TJM, Tiemeier H, Engelhart MJ, Fekkes D. Abnormal neurotransmitter metabolite levels in Alzheimer patients with a delirium. Int J Geriatr Psychiatry 2006;21:838-43. (14) Saravay SM, Kaplowitz M, Kurek J,et al. How Do Delirium and Dementia Increase Length of Stay of Elderly General Medical Inpatients? Psychosomatics 2004;45: 235-42. (15) O’Keeffe S. The experience of delirium in older people. Int Psychogeriatrics 2005;17: S2: 120. Competing interests: None declared |
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Jatinder K Juss, Specialist Registrar in Respiratory Medicine Norfolk & Norwich University Hospital NHS Trust, Colney Lane, Norwich, NR4 7UY, Duncan Forsyth, Consultant Geriatrician, Addenbrookes Hospital, Cambridge University Hospitals NHS Trust , Hills Road, Cambridge, CB2 0QQ
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In their excellent clinical review of ‘Delirium in older people’ Young and Inouye demonstrated the positive impact of risk factor reduction programmes on reducing the number and duration of delirium episodes in hospitalised elderly patients. However, their paper paid little attention to managing the aftermath of delirium. Young and Inouye do allude to the distressing nature of delirium but we feel do not emphasise the importance of counselling the individual upon recovery from their episode of delirium. Seeing a family member or friend during an episode of delirium is in itself distressing for many. A significant number of recovered patients and their families will also have lingering concerns that the episode of delirium represents the first step towards senility, madness and/or loss of independence. The patient may be ashamed or afraid to admit to symptoms and is often uncomfortable discussing their experiences with family, friends and healthcare professionals. This may even provoke avoidance behaviour such that some patients may not seek help for future medical problems. Relatives / carers play a fundamental role in planning and monitoring of care. Unless delirium is explained and managed sensitively, carers who are upset or poorly informed can form memories of loved ones "going mad” or disturbed and exacerbate a patient's distress. Clinic follow-up or a post-discharge visit to the treatment environment may facilitate adjustment and clarify the transient nature of delirium and may identify patients requiring further follow-up due to persisting cognitive deficits. Provision of information regarding the nature of delirium, its precipitants and predisposing factors will not only be helpful (to families and ward staff) at the time of an episode of delirium but may enable families and patients to forewarn medical and nursing staff at a subsequent hospital episode that they are at high risk of developing delirium, thereby facilitating an opportunity to reduce the chance of delirium occurring again. Competing interests: Both Dr. Juss and Dr. Forsyth co-author a web-based learning programme entitled Delirium in the Elderly on www.Doctors.net.uk |
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Leonardo Cocito, Associate Professor Dept. of Neurosciences, University of Genova, Via Antonio De Toni 5, I-16132 Genova Italy, Daniela Audenino, Paola Fontana, and Alberto Primavera
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In a recent article on delirium in the elderly, Young and Inouye (1) underscore that diagnosis of delirium rests solely on clinical skills, but overlook the usefulness of electroencephalogram (EEG) in these patients. The spectrum of differential diagnosis usually includes dementia, vascular, metabolic and psychiatric causes, while epilepsy and in particular non-convulsive status epilepticus (NCSE) are rarely considered in internal medicine and surgery departments. Late-onset de novo absence status epilepticus, however, has been reported in every tenth elderly patient with protracted ictal confusion (2). Varelas et al (3) reviewed the reports of all emergent EEGs (EmEEG) performed in Medical College of Wisconsin over a period of 52 months. The most common reason for the investigation was a change in mental status or coma; EmEEG was ordered to rule out status epilepticus in 60.2% of cases, this diagnosis being actually made in 10.7% of patients. We evaluated the role of EmEEG (records performed within 1-6 hours) in a general hospital population. In an 18-month period encompassing 2003 and 2004, 818 of 4273 EEGs (19.1%) were performed in our service. Of them, 338 were performed in 179 adult inpatients (mean age 76.5 ± 16.5 years) of internal medicine, emergency and surgery departments (several patients had more than one EEG records). We reviewed the reasons for EmEEG request and the clinical impact of EmEEG according to a slightly modified version of the guidelines proposed by Hillen and Sage (4). The most frequent causes of EmEEG request were acute confusional states (92 cases), unexplained brief loss of consciousness (36 cases), stupor and coma (31 cases). The EmEEG showed abnormalities in 161 patients (90%) and was deemed useful in 143 (80%). Clinical data and EEG findings suggested generalized NCSE in 21 patients with acute confusional state and showed focal epileptiform discharges in seven. Our data confirm that delirium and mental status changes in older patients were frequently related to a subclinical status epilepticus. Furthermore the EEG may be useful to identify patients with psychiatric disorders presenting with confusion or decreased level of consciousness. Bautista et al (5) suggested that an abbreviated (5-minute) EEG can be useful in the early assessment of patients who present to the emergency with mental status changes of unknown cause, without interrupting the routine workup of these patients. Patients with NCSE have an altered mental state, and as a practical guideline Husain et al (6) suggested that patients shall be selected for EmEEG when they have clinical and historical features strongly associated with NCSE. In our experience (7), however, patients with late-onset de novo NCSE often have neither history of previous seizures nor other peculiar clinical features pointing to this condition. According to Young and Inouye (1), recurrent brief cognitive testing (Mini-Mental State Examination, Confusion Assessment Method) are recommended for diagnosis of acute confusion in elderly patient. A suspicion of NCSE is the most clinical indication for an EmEEG. References 1) Young J, Inouye SK. Delirium in older people. BMJ 2007;334:842-6. 2) Sheth RD, Drazkowski JF, Sirven JI, Gidal BE, Hermann BP. Protracted ictal confusion in elderly patients. Arch Neurol 2006;63:529-32. 3) Varelas PN, Spanaki MV, Hacein-Bey L, Hether T, Terranova B. Emergent EEG: indications and diagnostic yield. Neurology 2003;61:702-4. 4) Hillen ME, Sage JI. Proving the worth of neurologists. Neurology 1996;46:276-7. 5) Bautista RE, Godwin S, Caro D. Incorporating abbreviated EEGs in the initial workup of patients who present to the emergency room with mental status changes of unknown etiology. J Clin Neurophysiol 2007;24:16-21. 6) Husain AM, Horn GJ, Jacobson MP. Non-convulsive status epilepticus: usefulness of clinical features in selecting patients for urgent EEG. J Neurol Neurosurg Psychiatry 2003;74:189-91. 7) Audenino D, Cocito L, Primavera A. Non-convulsive status epilepticus. J Neurol Neurosurg Psychiatry 2003;74:1599. Competing interests: None declared |
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Michael Patkin, retired general surgeon North Adelaide SA 5006 Australia
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Confusion after major surgery is much rarer than a generation ago but still occurs after hip replacement etc. leading to costly extra treatment and occasionally death. Sedation means it is more likely that causes of restlessness will be missed such as full bladder and wound pain. A simple classification lists causes from head to toes (1,2) and makes it more likely the junior intern on night duty will make the right diagnosis and solve an otherwise worsening problem. 1. Patkin M. Postoperative Confusion: a guide to management. Med. J. Aust., 1973, 2: 559-561 2. http://mpatkin.org/surgery_clinical/post_op_confusion.htm (accessed 19 May 2007) Competing interests: None declared |
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Domingo R Hidalgo, Geriatric specialist Sant Pau Hospital 08025-Barcelona, Francesc Formiga, Enric Duaso, Antonia Balet
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Sir, In a recent review, Young et al (1) suggested that atypical antipsychotics should be avoided in patients with dementia complicated by delirium because of the associated increased risk of stroke. Neuroleptic agents sholud be considered for treating delirium that has not adequately responded to nonpharmacologic measures. Given that haloperidol remains the recommended drug of choice for the treatment of delirium in acutelly ill patients. Therefore, avoidance of adverse effects is the primary factor to consider when making neuroleptic treatment decisions for elderly people with delirium. A recent systematic review (2) suggested that recommendation of one antipsychotic over another as a first-line pharmacologic intervention in the delirium is limited by the quality and quantity data available. In this systematic review, unfortunately, none of the trials evaluated patients according to delirium subtypes or attempted to stratity patients for this variable. This would be of particular interest, considering the response to antipsychotics may be different according to delirium subtypes. Recently, two systematic review have been published about pharmacologic treatment of delirium (3,4). These studies demonstrated that atypical antipsychotics are as efficacious as haloperidol and that may cause a number of adverse effects. The frequency of adverse effects varies among agents and is believe dependent on the relative affinity of each agent for specific receptors. Thus, the higher ratio of serotoninergic 5-HT2 versus dopaminergic D2 blockade seen with atypical antipsychotics compared with haloperidol is postulated to account for the lower frequency of extra pyramidal symptoms seen with atypical antipsychotics. On the other hand, orthostatic hypotension and prologation QTc interval are frequent adverse effects with use of haloperidol. Also, in comparison with risperidone, haloperidol has associated with greatest increase in mortality (5). Therefore, at the moment, there are no evidence to consider haloperidol as first-line therapy for delrium in older people because of a higher frequency extrapyramidal symptoms, hypotension, sedation, QTc prolongation, and mortality. For these reasons, treatment with atypical antipsychotics for delirium has recently been proposed in the pharmacologic treatment among elderly people (4). References 1. Young J, Inouye SK. Delirium in older people. BMJ 2007;334:842-846 2. Lacasse H, Perreault MM, Williamson DR. Systematic review of antipsychotics for the tretament of hospital-associated delirium in medically or surgically ill patients. Ann Pharmacother 2006;40:1966-1973 3. Seitz DP, Gill SS, van Zyl LT. Antipsychotics in the treatment of delirium: a systematic review. J Clin Psychiatry 2007;68 (1):11-21 4. Rea RS, Battistone S, Fong JJ, Devlin JW. Atypical antipsychotics versus haloperidol for the treatment of delirium in acutely ill patients. Pharmacotherapy 2007;27(4):588-594 5. Schneeweiss S, Setoguchi S, Brookhart A, Dormuth C, Wang PS. Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients. CMAJ 200/;17(5):627-632 Competing interests: None declared |
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