Efficacy of risperidone for prevention of postoperative delirium in cardiac surgery

Haloperidol prophylaxis does not prevent postoperative delirium in elderly patients: a randomized, open-label prospective trial

PURPOSE

Postoperative delirium is the most common postoperative complication in the elderly. The purpose of this study was to evaluate the safety and effectiveness of the preventive administration of low-dose haloperidol on the development of postoperative delirium after abdominal or orthopedic surgery in elderly patients.

SUBJECTS

A total of 119 patients aged 75 years or older who underwent elective surgery for digestive or orthopedic disease were included in this study.

METHODS

Patients were divided into those who did (intervention group, n = 59) and did not (control group, n = 60) receive 2.5 mg of haloperidol at 18:00 daily for 3 days after surgery; a randomized, open-label prospective study was performed on these groups. The primary endpoint was the incidence of postoperative delirium during the first 7 days after the operation.

RESULTS

The incidence of postoperative delirium in all patients was 37.8%. No side effects involving haloperidol were noted; however, the incidences of postoperative delirium were 42.4 and 33.3% in the intervention and control groups, respectively, which were not significantly different (p = 0.309). No significant effect of the treatment was observed on the severity or persistence of postoperative delirium.

CONCLUSIONS

The preventive administration of low-dose haloperidol did not induce any adverse events, but also did not significantly decrease the incidence or severity of postoperative delirium or shorten its persistence.

Improving delirium care through early intervention: from bench to bedside to boardroom

Delirium is a complex neuropsychiatric syndrome that impacts adversely upon patient outcomes and healthcare outcomes. Delirium occurs in approximately one in five hospitalised patients and is especially common in the elderly and patients who are highly morbid and/or have pre-existing cognitive impairment. However, efforts to improve management of delirium are hindered by gaps in our knowledge and issues that reflect a disparity between existing knowledge and real-world practice. This review focuses on evidence that can assist in prevention, earlier detection and more timely and effective pharmacological and non-pharmacological management of emergent cases and their aftermath. It points towards a new approach to delirium care, encompassing laboratory and clinical aspects and health services realignment supported by health managers prioritising delirium on the healthcare change agenda. Key areas for future research and service organisation are outlined in a plan for improved delirium care across the range of healthcare settings and patient populations in which it occurs.

Intensive care unit delirium: a review of the literature

PURPOSE

The recent literature regarding intensive care unit (ICU) delirium and updated clinical practice guidelines are reviewed.

SUMMARY

Recent studies show that ICU delirium in critically ill patients is an independent predictor of higher mortality, longer ICU and hospital stay, and is associated with multiple clinical complications. Delirium has been reported to occur in greater than 80% of hospitalized critically ill patients, yet it remains an underdiagnosed condition. Several subtypes of delirium have been identified including hypoactive, hyperactive, and mixed presentation. Although the exact mechanism is unknown, several factors are thought to interact to cause delirium. Multiple risk factors related to medications, acute illness, the environment, and patient characteristics may contribute to the development of delirium. Practical bedside screening tools have been validated and are recommended to identify ICU patients with delirium. Nonpharmacologic interventions such as early mobilization have resulted in better functional outcomes, decreased incidence and duration of delirium, and more ventilator-free days. Data supporting pharmacologic treatments are limited.

CONCLUSION

Clinicians should become familiar with tools to identify delirium in order to initiate treatment and remove mitigating factors early in hospitalization to prevent delirium. Pharmacists are in a unique position to reduce delirium through minimization of medication-related risk factors and development of protocols.

What do we really know about the treatment of delirium with antipsychotics? Ten key issues for delirium pharmacotherapy

Despite the significant burden of delirium among hospitalized adults, no pharmacologic intervention is approved for delirium treatment. Antipsychotic agents are the best studied but there are uncertainties as to how these agents can be optimally applied in everyday practice. We searched Medline and PubMed databases for publications from 1980 to April 2012 to identify studies of delirium treatment with antipsychotic agents. Studies of primary prevention using pharmacotherapy were not included. We identified 28 prospective studies that met our inclusion criteria, of which 15 were comparison studies (11 randomized), 2 of which were placebo-controlled. The quality of comparison studies was assessed using the Jadad scale. The DRS (N = 12) and DRS-R98 (N = 9) were the most commonly used instruments for measuring responsiveness. These studies suggest that around 75% of delirious patients who receive short-term treatment with low-dose antipsychotics experience clinical response. Response rates appear quite consistent across different patient groups and treatment settings. Studies do not suggest significant differences in efficacy for haloperidol versus atypical agents, but report higher rates of extrapyramidal side effects with haloperidol. Comorbid dementia may be associated with reduced response rates but this requires further study. The available evidence does not indicate major differences in response rates between clinical subtypes of delirium. The extent to which therapeutic effects can be explained by alleviation of specific symptoms (e.g. sleep or behavioral disturbances) versus a syndromal effect that encompasses both cognitive and noncognitive symptoms of delirium is not known. Future research needs to explore the relationship between therapeutic effects and changes in pathophysiological markers of delirium. Less than half of reports were rated as reasonable quality evidence on the Jadad scale, highlighting the need for future studies of better quality design, and in particular incorporating placebo-controlled work.

Prevention of ICU delirium and delirium-related outcome with haloperidol: a study protocol for a multicenter randomized controlled trial

Background

Delirium is a frequent disorder in intensive care unit (ICU) patients with serious consequences. Therefore, preventive treatment for delirium may be beneficial. Worldwide, haloperidol is the first choice for pharmacological treatment of delirious patients. In daily clinical practice, a lower dose is sometimes used as prophylaxis. Some studies have shown the beneficial effects of prophylactic haloperidol on delirium incidence as well as on mortality, but evidence for effectiveness in ICU patients is limited. The primary objective of our study is to determine the effect of haloperidol prophylaxis on 28-day survival. Secondary objectives include the incidence of delirium and delirium-related outcome and the side effects of haloperidol prophylaxis.

Methods

This will be a multicenter three-armed randomized, double-blind, placebo-controlled, prophylactic intervention study in critically ill patients. We will include consecutive non-neurological ICU patients, aged ≥18 years with an expected ICU length of stay >1 day. To be able to demonstrate a 15% increase in 28-day survival time with a power of 80% and alpha of 0.05 in both intervention groups, a total of 2,145 patients will be randomized; 715 in each group. The anticipated mortality rate in the placebo group is 12%. The intervention groups will receive prophylactic treatment with intravenous haloperidol 1 mg/q8h or 2 mg/q8h, and patients in the control group will receive placebo (sodium chloride 0.9%), both for a maximum period of 28-days. In patients who develop delirium, study medication will be stopped and patients will subsequently receive open label treatment with a higher (therapeutic) dose of haloperidol. We will use descriptive summary statistics as well as Cox proportional hazard regression analyses, adjusted for covariates.

Discussion

This will be the first large-scale multicenter randomized controlled prevention study with haloperidol in ICU patients with a high risk of delirium, adequately powered to demonstrate an effect on 28-day survival.

Trial registration

Clinicaltrials.gov: NCT01785290.

EudraCT number: 2012-004012-66.

Improving delirium care: prevention, monitoring, and assessment

Delirium is an acute change in awareness and attention and is common, morbid, and costly for patients and health care systems. While hyperactive delirium is easily identifiable, the hypoactive form is more common and carries a higher mortality. Hospital systems to address delirium should consist of 3 critical steps. First, hospitals must identify patients who develop or are at intermediate or high risk for delirium. Delirium risk may be assessed using known patient-based and illness-based risk factors, including preexisting cognitive impairment. Delirium diagnosis remains a clinical diagnosis that requires a clinical assessment that can be structured using diagnostic criteria. Hospital systems may be useful to efficiently allocate delirium resources to prevent and manage delirium. Second, it is crucial to develop a systematic approach to prevent delirium using multimodal nonpharmacologic delirium prevention methods and to monitor all high-risk patients for its occurrence. Tools such as the modified Richmond Agitation and Sedation Scale can aid in monitoring for changes in mental status that could indicate the development of delirium. Third, hospital systems can utilize established methods to assess and manage delirium in a standardized fashion. The key lies in addressing the underlying cause/causes of delirium, which often involve medical conditions or medications. With a sustained commitment, standardized efforts to identify and prevent delirium can mitigate the long-term morbidity associated with this acute change. In the face of changes in health care funding, delirium serves as an example of a syndrome where care coordination can improve short-term and long-term costs.

[Delirium in elderly patients]

BACKGROUND

Delirium, «acute confusional state», is a frequent and serious complication of acute illness, particularly in the elderly. The strain on the patient, the next of kin and the health service is considerable. The purpose of the article is to provide healthcare personnel who deal with delirium with updated information about the condition.

METHOD

The article is based on a literature search in PubMed combined with articles from the author's own archives and own clinical experience.

RESULTS

Delirium is a serious acute medical condition that is often overlooked in the elderly. The prevalence is estimated to be between 11% and 42% for elderly patients on medical wards and close to 50% in patients with hip fractures. The prevalence is probably also high in nursing homes, but this is less well surveyed. Advanced age and dementia are the most important risk factors. Traumas, infections, stroke and metabolic disturbances are the most common triggering factors. The pathophysiology is poorly surveyed and the possibilities for drug treatment are few and are little studied. Delirium is associated with increased risk of dementia, loss of function and mortality. Short-term use of low-dosage antipsychotics is the first-line choice, but is contraindicated for patients with Parkinsonian symptoms.

INTERPRETATION

Detection and treatment of triggering causes must have high priority in case of delirium. Non-drug interventions are most important to prevent and treat the condition.

Perioperative psycho-educational intervention can reduce postoperative delirium in patients after cardiac surgery: a pilot study

OBJECTIVE

Postoperative delirium after cardiac surgery is associated with many consequences such as poorer functional recovery, more frequent postoperative complications, higher mortality, increased length of hospital stay, and higher hospital costs. The aim of this study was to evaluate the efficacy of perioperative psycho-educational intervention in preventing postoperative delirium in post cardiac surgery patients.

METHOD

We conducted a comparative retrospective study between 49 patients who had received perioperative psycho-educational intervention and 46 patients who had received standard care. The primary outcome was the incidence of postoperative delirium. Secondary outcomes included length of ICU stay, and severity and duration of postoperative delirium among the patients who had developed delirium.

RESULTS

The incidence of postoperative delirium was significantly lower in the intervention group than that in the control group (12.24% vs. 34.78%, P = 0.009). Among the patients who had developed postoperative delirium, there was no statistical difference between the two groups regarding secondary outcomes.

CONCLUSIONS

Our results show that the patients who received perioperative psycho-educational intervention were associated with a lower incidence of postoperative delirium after cardiac surgery than those who received standard care. Clinicians would be able to implement this psycho-educational intervention as part of routine practice to reduce delirium.

Delirium in the intensive care unit

Delirium is a serious complication that commonly occurs in critically ill patients in the intensive care unit (ICU). Delirium is frequently unrecognized or missed despite its high incidence and prevalence, and leads to poor clinical outcomes and an increased cost by increasing morbidity, mortality, and hospital and ICU length of stay. Although its pathophysiology is poorly understood, numerous risk factors for delirium have been suggested. To improve clinical outcomes, it is crucial to perform preventive measures against delirium, to detect delirium early using valid and reliable screening tools, and to treat the underlying causes or hazard symptoms of delirium in a timely manner.

Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial

BACKGROUND

Delirium is frequently diagnosed in critically ill patients and is associated with poor clinical outcomes. Haloperidol is the most commonly used drug for delirium despite little evidence of its effectiveness. The aim of this study was to establish whether early treatment with haloperidol would decrease the time that survivors of critical illness spent in delirium or coma.

METHODS

We did this double-blind, placebo-controlled randomised trial in a general adult intensive care unit (ICU). Critically ill patients (≥18 years) needing mechanical ventilation within 72 h of admission were enrolled. Patients were randomised (by an independent nurse, in 1:1 ratio, with permuted block size of four and six, using a centralised, secure web-based randomisation service) to receive haloperidol 2.5 mg or 0.9% saline placebo intravenously every 8 h, irrespective of coma or delirium status. Study drug was discontinued on ICU discharge, once delirium-free and coma-free for 2 consecutive days, or after a maximum of 14 days of treatment, whichever came first. Delirium was assessed using the confusion assessment method for the ICU (CAM-ICU). The primary outcome was delirium-free and coma-free days, defined as the number of days in the first 14 days after randomisation during which the patient was alive without delirium and not in coma from any cause. Patients who died within the 14 day study period were recorded as having 0 days free of delirium and coma. ICU clinical and research staff and patients were masked to treatment throughout the study. Analyses were by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Registry, number ISRCTN83567338.

FINDINGS

142 patients were randomised, 141 were included in the final analysis (71 haloperidol, 70 placebo). Patients in the haloperidol group spent about the same number of days alive, without delirium, and without coma as did patients in the placebo group (median 5 days [IQR 0-10] vs 6 days [0-11] days; p=0.53). The most common adverse events were oversedation (11 patients in the haloperidol group vs six in the placebo group) and QTc prolongation (seven patients in the haloperidol group vs six in the placebo group). No patient had a serious adverse event related to the study drug.

INTERPRETATION

These results do not support the hypothesis that haloperidol modifies duration of delirium in critically ill patients. Although haloperidol can be used safely in this population of patients, pending the results of trials in progress, the use of intravenous haloperidol should be reserved for short-term management of acute agitation.

FUNDING

National Institute for Health Research.

Antipsychotic prophylaxis in surgical patients modestly decreases delirium incidence--but not duration--in high-incidence samples: a meta-analysis

OBJECTIVE

The objective was to examine whether prophylactic treatment with antipsychotics can decrease the incidence and severity of postsurgical delirium.

METHOD

A meta-analysis of existing trials comparing delirium incidence between patients given prophylactic antipsychotic and placebo was performed. Secondary outcomes were total hospital days, total days of delirium and severity. Pooled odds ratios (ORs) and mean differences were calculated using a random-effects model.

RESULTS

Five randomized placebo-controlled trials comprising a total of 1491 patients were included. In the pooled analysis, prophylactic antipsychotic administration showed a reduction in delirium incidence (OR: 0.42; 95% confidence interval (CI): 0.24, 0.74). Among the studies reporting other outcomes, patients receiving antipsychotics prophylactically showed no differences in total hospital days (0.1; 95% CI: -0.73, 0.94), days of delirium (-1.17; 95% CI: -5.22, 2.88) or delirium severity (-1.02; 95% CI: -6.81, 4.76).

CONCLUSIONS

Prophylactic antipsychotic treatment in surgical patients modestly decreases the incidence of delirium, but not the length of hospital stay, duration of delirium or its severity. Given the modest protective effect of antipsychotics and their potential adverse reactions, there is insufficient evidence to support its universal use as a preventive agent, though potential benefit may be seen in populations at high risk of developing delirium.

The pain, agitation, and delirium practice guidelines for adult critically ill patients: a post-publication perspective

The recently published Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit differ from earlier guidelines in the following ways: literature searches were performed in eight databases by a professional librarian; psychometric validation of assessment scales was considered in their recommendation; discrepancies in recommendation votes by guideline panel members are available in online supplements; and all recommendations were made exclusively on the basis of evidence available until December of 2010. Pain recognition and management remains challenging in the critically ill. Patient outcomes improve with routine pain assessment, use of co-analgesics and administration as well as dose adjustment of opiates to patient needs. Thoracic epidurals help ease patients undergoing abdominal aortic surgery. Little data exists to guide clinicians as to the type or dose of co-analgesics; no opiate choice is associated with better patient outcomes. Lighter or no sedation is beneficial, and interruption is desirable in patients who require deep sedation for specific pathologic states. Delirium screening is probably useful; no treatment modality can be unequivocally recommended, and the benefit of prophylaxis is established only for early mobilization. The details of these recommendations, as well as more recent publications that complement the guidelines, are provided in this commentary.

Strategies for prevention of postoperative delirium: a systematic review and meta-analysis of randomized trials

INTRODUCTION

The ideal measures to prevent postoperative delirium remain unestablished. We conducted this systematic review and meta-analysis to clarify the significance of potential interventions.

METHODS

The PRISMA statement guidelines were followed. Two researchers searched MEDLINE, EMBASE, CINAHL and the Cochrane Library for articles published in English before August 2012. Additional sources included reference lists from reviews and related articles from 'Google Scholar'. Randomized clinical trials (RCTs) on interventions seeking to prevent postoperative delirium in adult patients were included. Data extraction and methodological quality assessment were performed using predefined data fields and scoring system. Meta-analysis was accomplished for studies that used similar strategies. The primary outcome measure was the incidence of postoperative delirium. We further tested whether interventions effective in preventing postoperative delirium shortened the length of hospital stay.

RESULTS

We identified 38 RCTs with interventions ranging from perioperative managements to pharmacological, psychological or multicomponent interventions. Meta-analysis showed dexmedetomidine sedation was associated with less delirium compared to sedation produced by other drugs (two RCTs with 415 patients, pooled risk ratio (RR)=0.39; 95% confidence interval (CI)=0.16 to 0.95). Both typical (three RCTs with 965 patients, RR=0.71; 95% CI=0.54 to 0.93) and atypical antipsychotics (three RCTs with 627 patients, RR=0.36; 95% CI=0.26 to 0.50) decreased delirium occurrence when compared to placebos. Multicomponent interventions (two RCTs with 325 patients, RR=0.71; 95% CI=0.58 to 0.86) were effective in preventing delirium. No difference in the incidences of delirium was found between: neuraxial and general anesthesia (four RCTs with 511 patients, RR=0.99; 95% CI=0.65 to 1.50); epidural and intravenous analgesia (three RCTs with 167 patients, RR=0.93; 95% CI=0.61 to 1.43) or acetylcholinesterase inhibitors and placebo (four RCTs with 242 patients, RR=0.95; 95% CI=0.63 to 1.44). Effective prevention of postoperative delirium did not shorten the length of hospital stay (10 RCTs with 1,636 patients, pooled SMD (standard mean difference)=-0.06; 95% CI=-0.16 to 0.04).

CONCLUSIONS

The included studies showed great inconsistencies in definition, incidence, severity and duration of postoperative delirium. Meta-analysis supported dexmedetomidine sedation, multicomponent interventions and antipsychotics were useful in preventing postoperative delirium.

Treatment of delirium following cardiac surgery

Postoperative delirium is a common medical complication following cardiac surgery. This paper will outline the treatment options for delirium with a focus on prophylactic use of risperidone before cardiac surgery.

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit

OBJECTIVE

To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002.

METHODS

The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding.

CONCLUSION

These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

Future directions of delirium research and management

Delirium is a prevalent organ dysfunction in critically ill patients associated with significant morbidity and mortality, requiring advancements in the clinical and research realms to improve patient outcomes. Increased clinical recognition and utilisation of delirium assessment tools, along with clarification of specific risk factors and presentations in varying patient populations, will be necessary in the future. To improve predictive models for outcomes, the continued development and implementation of delirium assessment tools and severity scoring systems will be required. The interplay between the pathophysiological pathways implicated in delirium and resulting clinical presentations and outcomes will need to guide the development of appropriate prevention and treatment protocols. Multicentre randomised controlled trials of interventional therapies will then need to be performed to test their ability to improve clinical outcomes. Physical and cognitive rehabilitation measures need to be further examined as additional means of improving outcomes from delirium in the hospital setting.

Pharmacologic prevention and treatment of delirium in critically ill and non-critically ill hospitalised patients: a review of data from prospective, randomised studies

Delirium occurs commonly in acutely ill hospitalised patients, particularly in the elderly or in cardiac or orthopaedic surgery patients, or those in intensive care units (ICUs). Delirium worsens outcome. Pharmaceutical agents such as antipsychotics and, in the critically ill, dexmedetomidine, are considered therapeutic despite uncertainty regarding their efficacy and safety. Using MEDLINE, we reviewed randomised controlled trials (RCTs) published between 1977 and April 2012 evaluating a pharmacologic intervention to prevent or treat delirium in critically ill and non-critically ill hospitalised patients. The number of prospective RCTs remains limited. Any conclusions about pharmacologic efficacy are limited by the small size of many studies, the inconsistency by which non-pharmacologic delirium prevention strategies were incorporated, the lack of a true placebo arm and a failure to incorporate ICU and non-ICU clinical outcomes. A research framework for future evaluation of the use of medications in both ICU and non-ICU is proposed.

An update on delirium in the postoperative setting: prevention, diagnosis and management

Delirium is a serious and pervasive problem in the postoperative setting. Research to date has identified a number of key risk factors implicated in the development of delirium after surgical intervention, including advanced age, pre-existing cognitive impairment, lower pre-morbid functional status and history of psychiatric illness. Efforts to prevent postoperative delirium in the form of multi-component programs and prophylactic administration of medications have yielded some positive results. Studies investigating the effectiveness of various antipsychotics in the treatment of postoperative delirium have demonstrated somewhat mixed outcomes. Recent research has identified more sophisticated management of pain and sedation protocols as a way to prevent or mitigate delirium, with promising results. This chapter reviews the most recent literature pertaining to the prevention, diagnosis and management of postoperative delirium.

Haloperidol prophylaxis in critically ill patients with a high risk for delirium

Introduction

Delirium is associated with increased morbidity and mortality. We implemented a delirium prevention policy in intensive care unit (ICU) patients with a high risk of developing delirium, and evaluated if our policy resulted in quality improvement of relevant delirium outcome measures.

Methods

This study was a before/after evaluation of a delirium prevention project using prophylactic treatment with haloperidol. Patients with a predicted risk for delirium of ≥ 50%, or with a history of alcohol abuse or dementia, were identified. According to the prevention protocol these patients received haloperidol 1 mg/8 h. Evaluation was primarily focused on delirium incidence, delirium free days without coma and 28-day mortality. Results of prophylactic treatment were compared with a historical control group and a contemporary group that did not receive haloperidol prophylaxis mainly due to non-compliance to the protocol mostly during the implementation phase.

Results

In 12 months, 177 patients received haloperidol prophylaxis. Except for sepsis, patient characteristics were comparable between the prevention and the historical (n = 299) groups. Predicted chance to develop delirium was 75 ± 19% and 73 ± 22%, respectively. Haloperidol prophylaxis resulted in a lower delirium incidence (65% vs. 75%, P = 0.01), and more delirium-free-days (median 20 days (IQR 8 to 27) vs. median 13 days (3 to 27), P = 0.003) in the intervention group compared to the control group. Cox-regression analysis adjusted for sepsis showed a hazard rate of 0.80 (95% confidence interval 0.66 to 0.98) for 28-day mortality. Beneficial effects of haloperidol appeared most pronounced in the patients with the highest risk for delirium. Furthermore, haloperidol prophylaxis resulted in less ICU re-admissions (11% vs. 18%, P = 0.03) and unplanned removal of tubes/lines (12% vs. 19%, P = 0.02). Haloperidol was stopped in 12 patients because of QTc-time prolongation (n = 9), renal failure (n = 1) or suspected neurological side-effects (n = 2). No other side-effects were reported. Patients who were not treated during the intervention period (n = 59) showed similar results compared to the untreated historical control group.

Conclusions

Our evaluation study suggests that prophylactic treatment with low dose haloperidol in critically ill patients with a high risk for delirium probably has beneficial effects. These results warrant confirmation in a randomized controlled trial.

Trial registration

clinicaltrial.gov Identifier: NCT01187667.

Optimizing drug therapy in the surgical intensive care unit

This article provides a review of commonly prescribed medications in the surgical ICU, focusing on sedatives, antipsychotics, neuromuscular blocking agents, cardiovascular agents, anticoagulants, and antibiotics. A brief overview of pharmacology is followed by practical considerations to aid prescribers in selecting the best therapy within a given category of drugs to optimize patient outcomes.

Preventing delirium in the intensive care unit

Delirium in the intensive care unit (ICU) is exceedingly common, and risk factors for delirium among the critically ill are nearly ubiquitous. Addressing modifiable risk factors including sedation management, deliriogenic medications, immobility, and sleep disruption can help to prevent and reduce the duration of this deadly syndrome. The ABCDE approach to critical care is a bundled approach that clinicians can implement for many patients treated in their ICUs to prevent the adverse outcomes associated with delirium and critical illness.

The impact of intra- and postoperative albumin levels as a biomarker of delirium after cardiopulmonary bypass: results of an exploratory study

In this prospective study the frequency of delirium after cardiac surgery with cardiopulmonary bypass (CPB) was determined. Furthermore, we investigated the impact of intra- and postoperative levels of albumin as a biomarker of delirium. Thirty-four patients who underwent elective CPB at the Department of Cardiac Surgery, Ludwig-Maximilians-University of Munich, Germany, were enroled in this prospective study. During the intensive care unit (ICU) stay and shortly after discharge from the ICU, delirious state was evaluated daily using the Delirium-Rating-Scale. Albumin was assayed pre-anaesthesia, immediately after induction of anaesthesia, at the beginning of the heart-lung-apparatus period, immediately before the opening and 5min after the opening of the aortic clamp, 24h and 48h postoperatively and on the day before discharge. After CPB, a clinical significant delirious state was observed in 11 patients (32.4%). The albumin level decreased during the surgical intervention and increased postoperatively with a maximum level at the time of discharge. CPB patients with delirious state showed a significantly lower albumin level 24h and 48h postoperatively than those without delirium. A low level of postoperative albumin seems to be a useful biomarker to identify patients with high risk of delirious state after CPB.

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

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

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

BACKGROUND

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

PURPOSE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSION

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

Pharmacological risk factors for delirium after cardiac surgery: a review

PURPOSE

The objective of this review is to evaluate the literature on medications associated with delirium after cardiac surgery and potential prophylactic agents for preventing it.

SOURCE

Articles were searched in MEDLINE, Cumulative Index to Nursing and Allied Health, and EMBASE with the MeSH headings: delirium, cardiac surgical procedures, and risk factors, and the keywords: delirium, cardiac surgery, risk factors, and drugs. Principle inclusion criteria include having patient samples receiving cardiac procedures on cardiopulmonary bypass, and using DSM-IV-TR criteria or a standardized tool for the diagnosis of delirium.

PRINCIPAL FINDINGS

Fifteen studies were reviewed. Two single drugs (intraoperative fentanyl and ketamine), and two classes of drugs (preoperative antipsychotics and postoperative inotropes) were identified in the literature as being independently associated with delirium after cardiac surgery. Another seven classes of drugs (preoperative antihypertensives, anticholinergics, antidepressants, benzodiazepines, opioids, and statins, and postoperative opioids) and three single drugs (intraoperative diazepam, and postoperative dexmedetomidine and rivastigmine) have mixed findings. One drug (risperidone) has been shown to prevent delirium when taken immediately upon awakening from cardiac surgery. None of these findings was replicated in the studies reviewed.

CONCLUSION

These studies have shown that drugs taken perioperatively by cardiac surgery patients need to be considered in delirium risk management strategies. While medications with direct neurological actions are clearly important, this review has shown that specific cardiovascular drugs may also require attention. Future studies that are methodologically consistent are required to further validate these findings and improve their utility.

A brief review of practical preoperative cognitive screening tools

PURPOSE

Preoperative cognitive impairment is associated with the development of postoperative delirium, a common and consequential complication of major surgery in older patients. Screening for cognitive impairment should become a routine part of the preoperative evaluation of older patients; however, its implementation is hampered by limited clinical time and resources. The objective of this review was to identify cognitive screening tools that could be easily incorporated into the evaluation of older patients before major surgery.

SEARCH STRATEGY

Using strict inclusion and exclusion criteria, we searched PubMed over a 15-year period for short and simple cognitive screening tools. In addition, we reviewed studies that examined these cognitive screening tools in a perioperative environment. SEARCH RESULTS: We identified six cognitive screening tools that could each be administered in 2.5 min or less. Among the tools, sensitivity for cognitive impairment ranged from 79-99%, while specificity ranged from 70-98%. Only one (Mini-Cog) of the six tools we identified had been tested in a perioperative environment.

CONCLUSIONS

Incorporating a cognitive screening assessment into the preoperative evaluation of older patients is feasible. More research is needed to validate cognitive screening tools in the perioperative setting.

Antipsychotic use and diagnosis of delirium in the intensive care unit

INTRODUCTION

Delirium is an independent risk factor for prolonged hospital length of stay (LOS) and increased mortality. Several antipsychotics have been studied for the treatment of intensive care unit (ICU) delirium that has led to a high variability in prescribing patterns for these medications. We hypothesize that in clinical practice the documentation of delirium is lower than the incidence of delirium reported in prospective clinical trials. The objective of this study was to document the incidence of delirium diagnosed in ICU patients and to describe the utilization of antipsychotics in the ICU.

METHODS

This was a retrospective, observational, cohort study conducted at 71 United States academic medical centers that reported data to the University Health System Consortium Clinical Database/Resource Manager. It included all patients 18 years of age and older admitted to the hospital between 1 January 2010 and 30 June 2010 with at least one day in the ICU.

RESULTS

Delirium was diagnosed in 6% (10,034 of 164,996) of hospitalizations with an ICU admission. Antipsychotics were administered to 11% (17,764 of 164,996) of patients. Of the antipsychotics studied, the most frequently used were haloperidol (62%; n = 10,958) and quetiapine (31%; n = 5,448). Delirium was associated with increased ICU LOS (5 vs. 3 days, P < 0.001) and hospital LOS (11 vs. 6 days, P < 0.001), but not in-hospital mortality (8% vs. 9%, P = 0.419). Antipsychotic exposure was associated with increased ICU LOS (8 vs. 3 days, P < 0.001), hospital LOS (14 vs. 5 days, P < 0.001) and mortality (12% vs. 8%, P < 0.001). Of patients with antipsychotic exposure in the ICU, absence of a documented mental disorder (32%, n = 5,760) was associated with increased ICU LOS (9 vs. 7 days, P < 0.001), hospital LOS (16 vs. 13 days, P < 0.001) and in-hospital mortality (19% vs. 9%, P < 0.001) compared to patients with a documented mental disorder (68%, n = 12,004).

CONCLUSIONS

The incidence of documented delirium in ICU patients is lower than that documented in previous prospective studies with active screening. Antipsychotics are administered to 1 in every 10 ICU patients. When administration occurs in the absence of a documented mental disorder, antipsychotic use is associated with an even higher ICU and hospital LOS, as well as in-hospital mortality.

Evidence-based treatment of delirium in patients with cancer

Delirium is the most common neuropsychiatric complication seen in patients with cancer, and it is associated with significant morbidity and mortality. Increased health care costs, prolonged hospital stays, and long-term cognitive decline are other well-recognized adverse outcomes of delirium. Improved recognition of delirium and early treatment are important in diminishing such morbidity. There has been an increasing number of studies published in the literature over the last 10 years regarding delirium treatment as well as prevention. Antipsychotics, cholinesterase inhibitors, and alpha-2 agonists are the three groups of medications that have been studied in randomized controlled trials in different patient populations. In patients with cancer, the evidence is most clearly supportive of short-term, low-dose use of antipsychotics for controlling the symptoms of delirium, with close monitoring for possible adverse effects, especially in older patients with multiple medical comorbidities. Nonpharmacologic interventions also appear to have a beneficial role in the treatment of patients with cancer who have or are at risk for delirium. This article presents evidence-based recommendations based on the results of pharmacologic and nonpharmacologic studies of the treatment and prevention of delirium.

A review of pharmacologic management and prevention strategies for delirium in the intensive care unit

BACKGROUND

The prevalence of delirium has been estimated at anywhere between 10% and 30% in general medical patients and in upwards of 80% in patients who are admitted to an intensive care unit (ICU). Given the high prevalence of delirium in the ICU population, it should not be surprising that a large percentage of psychiatric consults arise from this setting. While the mainstay of pharmacologic management of delirium centers on neuroleptic medications, such as haloperidol, recent studies using alternate agents have shown varying levels of promise.

OBJECTIVE

Our purpose is to outline the major prospective studies looking at the efficacy of pharmacologic management and prevention strategies for delirium exclusively in adult ICU patients. Both conventional and novel pharmacotherapeutic interventions are discussed.

METHOD

Articles were obtained using the MEDLINE/PUBMED database looking specifically at pharmacologic interventions for delirium in the intensive care unit. A search was performed using the key words"delirium," "intensive care unit," "treatment," and "prophylaxis." The authors limited their search to prospective studies, specifically randomized trials (both placebo-controlled and non-controlled) in the adult ICU population, and eliminated retrospective and observational studies. Relevant citations from the previously mentioned articles were also included in the review.

CONCLUSION

There is a plethora of studies on pharmacologic management strategies in general medical patients with delirium. Findings from these studies are often extrapolated to the ICU population; however, when looking at studies limited to ICU patients with delirium, there are far fewer credible prospective studies.

A review of recent clinical trials and guidelines on the prevention and management of delirium in hospitalized older patients

Treatment of acute illness in older adults is frequently complicated by the presence of delirium. Delirium is characterized by the development of an altered mental status over the course of hours to days, and can have a fluctuating course. Patients with delirium have difficulty paying attention to their environment, have disorganized thinking, and usually have an altered level of consciousness. While scientists continue to elucidate the pathophysiologic mechanisms associated with delirium, clinicians can identify patients at risk for delirium and diagnose it using valid instruments, such as the Confusion Assessment Method and Confusion Assessment Method for the Intensive Care Unit. Delirium is an independent risk factor for death, institutionalization, and dementia, and resolves in many patients by the time of hospital discharge. For patients admitted to medical units, optimal management of delirium includes reassessment of medications, pain, sleep, nutrition, mobility, need for physical restraints, and bowel and bladder function. The use of antipsychotic medication to sedate delirious patients should be restricted to patients in danger of harming themselves or others and should be used when nonpharmacologic means fail. Multicomponent interventions performed by the hospital care team that address risk factors can prevent delirium in patients in medical units and those undergoing hip fracture repair. This includes attention to the depth of sedation during spinal anesthesia and the addition of regional nerve blocks to patient-controlled analgesia in orthopedic patients, both of which may reduce postoperative delirium. Perioperative use of antipsychotics may further reduce the incidence of delirium, although hospital length of stay has not been routinely reduced. Appropriate management of analgesia, sedation, and delirium in the intensive care unit is also associated with reduced duration of mechanical ventilation, as well as intensive care unit and hospital length of stay. The use of dexmedetomidine, an α-adrenergic receptor agonist, for sedation may reduce intensive care unit length of stay when compared with use of benzodiazepines.

Paliperidone in the treatment of delirium: results of a prospective open-label pilot trial

Yoon H-K, Kim Y-K, Han C, Ko Y-H, Lee H-J, Kwon D-Y, Kim L. Paliperidone in the treatment of delirium: results of a prospective open-label pilot trial.

Objective: Delirium is a life-threatening neuropsychiatric syndrome characterised by disturbances in consciousness, attention, cognition and perception. Antipsychotics are considered the drugs of choice in managing the symptoms of delirium. Paliperidone is a benzisoxazole derivative and the principal active metabolite of risperidone. In this study, we aimed to evaluate the efficacy of paliperidone for the treatment of delirium.

Methods: A prospective open-label study of paliperidone for delirium treatment was performed with 6-day follow-up. Fifteen patients who met Diagnostic and Statistical Manual of Mental disorders, Fourth Edition criteria for delirium and had a score of 13 on the Delirium Rating Scale were recruited. The starting dose was 3 mg once a day and the dose was adjusted depending on the status of delirium. Daily assessments of the severity of delirium were evaluated using Memorial Delirium Assessment Scale (MDAS).

Results: The mean daily maintenance dose of paliperidone was 3.75 ± 1.06. The MDAS scores before and after treatment (day 7) were 23.60 ± 6.31 and 11.33 ± 5.45 (t = 6.78, p < 0.001), respectively. The intensity of delirium showed a statistically significant reduction in MDAS scores from the first day of treatment. No serious adverse effects were observed, and none of the patients discontinued paliperidone because of adverse effects.

Conclusions: This study shows that low-dose paliperidone is effective in reducing behavioural disturbances and symptoms in delirium and is well tolerated in delirious patients. This trial is an open-label study with a small sample size, and further controlled studies will be necessary.

A clinical update on delirium: from early recognition to effective management

Delirium is a neuropsychiatric syndrome characterized by altered consciousness and attention with cognitive, emotional and behavioural symptoms. It is particularly frequent in elderly people with medical or surgical conditions and is associated with adverse outcomes. Predisposing factors render the subject more vulnerable to a congregation of precipitating factors which potentially affect brain function and induce an imbalance in all the major neurotransmitter systems. Early diagnosis of delirium is crucial to improve the prognosis of patients requiring the identification of subtle and fluctuating signs. Increased awareness of clinical staff, particularly nurses, and routine screening of cognitive function with standardized instruments, can be decisive to increase detection rates of delirium. General measures to prevent delirium include the implementation of protocols to systematically identify and minimize all risk factors present in a particular clinical setting. As soon as delirium is recognized, prompt removal of precipitating factors is warranted together with environmental changes and early mobilization of patients. Low doses of haloperidol or olanzapine can be used for brief periods, for the behavioural control of delirium. All of these measures are a part of the multicomponent strategy for prevention and treatment of delirium, in which the nursing care plays a vital role.

Structured analyses of interventions to prevent delirium

BACKGROUND

Delirium is one of the most serious complications in hospitalized elderly, with incidences ranging from 3-56%. The objective of this meta-analysis was two-fold, first to investigate if interventions to prevent delirium are effective and second to explore which factors increase the effectiveness of these interventions.

METHODS

An electronic search was carried out on articles published between January 1979 and July 2009. Abstracts were reviewed, data were extracted and methodologic quality was assessed by two independent reviewers. Effect sizes of the interventions were expressed as ORs (odds ratios) and 95%CIs (confidence intervals). A random effect model was used to provide pooled ORs. To explore which factors increase the effectiveness of the interventions, ORs were stratified for several factors.

RESULTS

Sixteen relevant studies were found. Overall the included studies showed a positive result of any intervention to prevent delirium (pooled OR: 0.64; 95%CI: 0.46-0.88). The largest effect was seen in studies on populations with an incidence of delirium above 30% in the control group (pooled OR: 0.34; 95%CI: 0.16-0.71 versus 0.76; 95%CI: 0.60-0.97).

CONCLUSIONS

Interventions to prevent delirium are effective. Interventions seem to be more effective when the incidence of delirium in the population under study is above 30%. To maximize the options for a cost-effective strategy of delirium prevention it might be useful to offer an intervention to a selected population.

Review articles: the effects of perioperative and intensive care unit sedation on brain organ dysfunction

Analgesia and sedation are routinely administered to patients in procedural suites, operating rooms, and intensive care units to permit invasive procedures, prevent pain and anxiety, reduce stress and oxygen consumption, allow mechanical ventilation, and for numerous other patient comfort and safety reasons. Increasing research and evidence, however, has implicated commonly prescribed sedative medications as risk factors for untoward events and worse patient outcomes, including brain organ dysfunction manifested as delirium and coma. The effect of sedatives on outcomes is also influenced by the depth of sedation, making it imperative to reduce total exposure to this class of medications. Juxtaposing the widespread necessity and use of sedation with the cost of acute and long-term cognitive dysfunction to patients and society, physicians must now strive to balance patients' demands and requisite for comfort with their own oath to do no harm. Fortunately, our methods of sedation and choice of medications can likely mitigate this cognitive risk. In this review, we detail the effects of perioperative and intensive care unit sedation on the development of delirium and cognitive impairment and provide an evidence-based approach towards analgesia and sedation paradigms to improve patient outcomes.