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Henmi R, Nakamura T, Mashimoto M, Takase F, Ozone M. Preventive Effects of Ramelteon, Suvorexant, and Lemborexant on Delirium in Hospitalized Patients With Physical Disease: A Retrospective Cohort Study. J Clin Psychopharmacol 2024; 44:369-377. [PMID: 38820374 DOI: 10.1097/jcp.0000000000001876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
BACKGROUND New sleep-inducing drugs (eg, ramelteon, suvorexant, and lemborexant) have been shown to prevent delirium in high-risk groups. However, no single study has simultaneously evaluated the delirium-preventing effects of all novel sleep-inducing drugs in hospitalized patients. Therefore, this study aimed to clarify the relationship between sleep-inducing drugs and delirium prevention in patients hospitalized in general medical-surgical settings for nonpsychiatric conditions who underwent liaison interventions for insomnia. METHODS This retrospective cohort study included patients treated in general medical-surgical settings for nonpsychiatric conditions with consultation-liaison psychiatry consult for insomnia. Delirium was diagnosed by fully certified psychiatrists using the Diagnostic and Statistical Manual of Mental Disorders 5 th edition. The following items were retrospectively examined from medical records as factors related to delirium development: type of sleep-inducing drugs, age, sex, and delirium risk factors. The risk factors of delirium development were calculated using adjusted odds ratios (aORs) via multivariate logistic regression analysis. RESULTS Among the 710 patients analyzed, 257 (36.2%) developed delirium. Suvorexant (aOR, 0.61; 95% confidence interval [CI], 0.40-0.94; P = 0.02) and lemborexant (aOR, 0.23; 95% CI, 0.14-0.39; P < 0.0001) significantly reduced the risk of developing delirium. Benzodiazepines (aOR, 1.90; 95% CI, 1.15-3.13; P = 0.01) significantly increased this risk. Ramelteon (aOR, 1.30; 95% CI, 0.84-2.01; P = 0.24) and Z-drugs (aOR, 1.27; 95% CI, 0.81-1.98; P = 0.30) were not significantly associated with delirium development. CONCLUSIONS The use of suvorexant and lemborexant may prevent delirium in patients with a wide range of medical conditions.
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Affiliation(s)
- Ryuji Henmi
- From the Department of Neuropsychiatry, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Tomoyuki Nakamura
- From the Department of Neuropsychiatry, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | | | | | - Motohiro Ozone
- From the Department of Neuropsychiatry, Kurume University School of Medicine, Kurume, Fukuoka, Japan
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Singh G, Nguyen C, Kuschner W. Pharmacologic Sleep Aids in the Intensive Care Unit: A Systematic Review. J Intensive Care Med 2024:8850666241255345. [PMID: 38881385 DOI: 10.1177/08850666241255345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Background: Patients in the intensive care unit (ICU) often experience poor sleep quality. Pharmacologic sleep aids are frequently used as primary or adjunctive therapy to improve sleep, although their benefits in the ICU remain uncertain. This review aims to provide a comprehensive assessment of the objective and subjective effects of medications used for sleep in the ICU, as well as their adverse effects. Methods: PubMed, Web of Science, Scopus, Embase, and Cochrane Central Register of Controlled Trials were systematically searched from their inception until June 2023 for comparative studies assessing the effects of pharmacologic sleep aids on objective and subjective metrics of sleep. Results: Thirty-four studies with 3498 participants were included. Medications evaluated were melatonin, ramelteon, suvorexant, propofol, and dexmedetomidine. The majority of studies were randomized controlled trials. Melatonin and dexmedetomidine were the best studied agents. Objective sleep metrics included polysomnography (PSG), electroencephalography (EEG), bispectral index, and actigraphy. Subjective outcome measures included patient questionnaires and nursing observations. Evidence for melatonin as a sleep aid in the ICU was mixed but largely not supportive for improving sleep. Evidence for ramelteon, suvorexant, and propofol was too limited to offer definitive recommendations. Both objective and subjective data supported dexmedetomidine as an effective sleep aid in the ICU, with PSG/EEG in 303 ICU patients demonstrating increased sleep duration and efficiency, decreased arousal index, decreased percentage of stage N1 sleep, and increased absolute and percentage of stage N2 sleep. Mild bradycardia and hypotension were reported as side effects of dexmedetomidine, whereas the other medications were reported to be safe. Several ongoing studies have not yet been published, mostly on melatonin and dexmedetomidine. Conclusions: While definitive conclusions cannot be made for most medications, dexmedetomidine improved sleep quantity and quality in the ICU. These benefits need to be balanced with possible hemodynamic side effects.
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Affiliation(s)
- Gaurav Singh
- Pulmonary, Critical Care, and Sleep Medicine Section, Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Christopher Nguyen
- Pulmonary, Critical Care, and Sleep Medicine Section, Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Ware Kuschner
- Pulmonary, Critical Care, and Sleep Medicine Section, Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Palo Alto, CA, USA
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Dobry P, Poparad-Stezar A, Bacon O, Boji S, Giuliano C. Does Melatonin Decrease the Use of As-Needed Antipsychotics or Benzodiazepines in Noncritically Ill Hospitalized Patients? A Multicenter Retrospective Cohort Study. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2024; 30:554-559. [PMID: 37976107 DOI: 10.1089/jicm.2023.0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Background: Delirium is a common neuropsychiatric syndrome without an FDA-approved treatment. Commonly used modalities show little improvement in outcomes; therefore, prevention efforts are imperative. Abnormalities in the sleep/wake cycle have been linked to delirium, and melatonin has been proposed to replace the hypothesized low levels of endogenous melatonin and restore sleep/wake cycle synchronization. Objectives: The primary objective of this study was to evaluate the association between melatonin, benzodiazepines (BZDs) or zolpidem (ZLP), and the use of as-needed antipsychotics and BZDs for delirium in noncritically ill adult patients. Methods: This was a multicenter retrospective cohort study of noncritically ill adult patients admitted to two separate health systems from August 2012 to December 2018 receiving either melatonin or nonmelatonin medications (ZLP or BZDs) for sleep. The coprimary endpoint was the proportion of patients receiving a pro re nata (PRN) antipsychotic or BZD 5 days from the patient's first dose of melatonin, BZD, or ZLP. Secondary outcomes included evaluation of the coprimary outcome in patients 65 years of age or older, total number of PRN antipsychotic and BZD doses, and length of stay. Results: Two hundred and twenty-five patients were included in the final analysis. Administration of BZD or ZLP was associated with a higher risk of subsequent BZD administration as compared with melatonin (OR 2.78, 95% CI 1.2-1.87) and ZLP (OR 2.78, 95% CI 1.25-6.17). BZD or ZLP had no impact on PRN antipsychotic use compared with melatonin (OR 1.09, 95% CI 0.51-2.35) and ZLP (OR 1.16, 95% CI 0.56-2.4). Conclusion: Melatonin use was found to be associated with a significant decrease in PRN BZD use in noncritically ill patients hospitalized on general floors; however, there was no observed association with overall PRN antipsychotic use. These results suggest that using melatonin may help decrease utilization of medications commonly used to manage delirium.
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Affiliation(s)
- Paul Dobry
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
- Department of Pharmacy Practice, Wayne State University, Detroit, MI, USA
| | | | - Opal Bacon
- Department of Pharmacy, United States Department of Veterans Affairs, Grand Island, NE, USA
| | - Sharon Boji
- Department of Pharmacy, Henry Ford Health System, Detroit, MI, USA
| | - Christopher Giuliano
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
- Department of Pharmacy Practice, Wayne State University, Detroit, MI, USA
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Zelenkov D, Hollins R, Mahoney EJ, Faugno AJ, Poyant J. The Impact of a Pharmacist-Driven Multicomponent Sleep-Promoting Protocol on Delirium in Critically Ill Patients. J Pharm Pract 2024; 37:578-586. [PMID: 36594245 DOI: 10.1177/08971900221148581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background: Sleep deprivation is reported in 80% of patients in the intensive care unit (ICU) and is associated with delirium. Guidelines recommend implementing a sleep-promoting protocol in critically ill patients which may increase the quantity and quality of sleep and may decrease delirium. Our objective was to implement a pharmacist-led interdisciplinary sleep-promoting protocol and analyze its impact on delirium in ICU patients receiving mechanical ventilation (MV). Methods: The study involved pre-implementation education, protocol development, and post-implementation analysis. ICU pharmacists completed prospective patient chart reviews to reduce exposure to deliriogenic medications and assess the need for a pharmacologic sleep aid. The primary outcome was the incidence of delirium and delirium-free days. Secondary outcomes included ICU length of stay (LOS), incidence of MV, and pharmacist medication interventions. Results: Post-protocol patients (n = 185) had a higher incidence of delirium compared to pre-protocol patients (n = 237) (51.3% vs 39.0%; P = .01). Post-protocol patients had a higher average APACHE III score (P = <.001). Delirium-free days were not significantly different between groups (P = .97). Difference in ICU LOS was not significant (P = .80). More patients received MV post-protocol implementation (55.7% vs 36.1%; P < .001). Pharmacists documented a total of 113 medication interventions. Conclusion and Relevance: A pharmacist-led, ICU sleep-promoting protocol was successfully implemented but did not reduce the incidence of delirium or the administration of insomnia agents. Post-protocol patients had higher disease severity and were more likely to receive MV. Incidence of delirium was consistent with the national reported prevalence of ICU delirium. ICU pharmacists on all shifts had an active role in optimizing sleep.
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Affiliation(s)
| | - Randy Hollins
- Department of Pharmacy, Melrose Wakefield Healthcare, Melrose, MA, USA
| | - Eric J Mahoney
- Department of Surgical Critical Care, Lahey Hospital & Medical Center, Burlington, MA, USA
| | - Anthony J Faugno
- Department of Critical Care, Sleep and Pulmonary Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Janelle Poyant
- Department of Pharmacy, Tufts Medical Center, Boston, MA, USA
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Lange PW, Turbić A, Soh CH, Clayton-Chubb D, Lim WK, Conyers R, Watson R, Maier AB. Melatonin does not reduce delirium severity in hospitalized older adults: Results of a randomized placebo-controlled trial. J Am Geriatr Soc 2024; 72:1802-1809. [PMID: 38438279 DOI: 10.1111/jgs.18825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 01/01/2024] [Accepted: 01/14/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Delirium is common in older inpatients, causing distress, cognitive decline, and death. Current therapies are unsatisfactory, limited by lack of efficacy and adverse effects. There is an urgent need for effective delirium treatment. Sleep wake cycle is disturbed in delirium; endogenous Melatonin is perturbed, and exogenous Melatonin is a safe and effective medication for sleep disorders. This study aims to determine the effect of oral Melatonin 5 mg immediate release (IR) nightly for five nights on the severity of delirium in older (≥65 years) medical inpatients. METHODS This was a double-blinded, randomized controlled trial in general internal medicine units of a tertiary teaching hospital. Older inpatients with Confusion Assessment Method positive, hyperactive or mixed delirium within 48 h of admission or onset of in-hospital delirium were included. The primary outcome was change in delirium severity measured with the Memorial Delirium Assessment Scale (MDAS). A previous pilot trial showed 120 participants randomized 1:1 to Melatonin or Placebo would provide 90% power to demonstrate a 3-point reduction in the MDAS. RESULTS One hundred and twenty participants were randomized, 61 to Melatonin 5 mg and 59 to Placebo. The medication was well tolerated. The mean MDAS improvement was 4.9 (SD 7.6) in the Melatonin group and 5.4 (SD 7.2) in the Placebo group, p-value 0.42, a non-significant difference. A post-hoc analysis showed length of stay (LOS) was shorter in the intervention group (median 9 days [Interquartile Range (IQR) 4, 12] vs. Placebo group 10 [IQR 6, 16] p-value = 0.033, Wilcoxon Rank Sum test). CONCLUSIONS This trial does not support the hypothesis that Melatonin reduces the severity of delirium. This may be due to no effect of Melatonin, a smaller effect than anticipated, an effect not captured on a multidimensional delirium assessment scale, or a type II statistical error. Melatonin may improve LOS; this hypothesis should be studied.
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Affiliation(s)
- Peter W Lange
- Department of Aged Care and Medicine, The Royal Melbourne Hospital, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
- Department of Geriatrics and General Medicine, Werribee Mercy Hospital, Werribee, Victoria, Australia
| | - Alisa Turbić
- Bone and Fractures Research Program, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Cheng Hwee Soh
- Department of Aged Care and Medicine, The Royal Melbourne Hospital, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Daniel Clayton-Chubb
- Department of Gastroenterology, Alfred Health, Prahran, Victoria, Australia
- Department of Gastroenterology, Eastern Health, Box Hill, Victoria, Australia
- Department of Medicine, Central Clinical School, Monash University, Victoria, Australia
| | - Wen Kwang Lim
- Department of Aged Care and Medicine, The Royal Melbourne Hospital, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Rachel Conyers
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Heart Disease, Stem Cell Biology, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Rosie Watson
- Department of Aged Care and Medicine, The Royal Melbourne Hospital, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia
| | - Andrea B Maier
- Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
- Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore, Singapore
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Shin HW, Kwak JS, Choi YJ, Kim JW, You HS, Shin HJ, Jang YK. Efficacy and safety of perioperative melatonin for postoperative delirium in patients undergoing surgery: a systematic review and meta-analysis. J Int Med Res 2024; 52:3000605241239854. [PMID: 38735057 PMCID: PMC11089947 DOI: 10.1177/03000605241239854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/29/2024] [Indexed: 05/14/2024] Open
Abstract
OBJECTIVE To assess the efficacy and safety of perioperative melatonin and melatonin agonists in preventing postoperative delirium (POD). METHODS We conducted a systematic search for randomized controlled trials (RCTs) published through December 2022. The primary outcome was efficacy based on the incidence of POD (POD-I). Secondary outcomes included efficacy and safety according to the length of hospital or intensive care unit stay, in-hospital mortality, and adverse events. Subgroup analyses of POD-I were based on the type and dose of drug (low- and high-dose melatonin, ramelteon), the postoperative period (early or late), and the type of surgery. RESULTS In the analysis (16 RCTs, 1981 patients), POD-I was lower in the treatment group than in the control group (risk ratio [RR] = 0.57). POD-I was lower in the high-dose melatonin group than in the control group (RR = 0.41), whereas no benefit was observed in the low-dose melatonin and ramelteon groups. POD-I was lower in the melatonin group in the early postoperative period (RR = 0.35) and in patients undergoing cardiopulmonary surgery (RR = 0.54). CONCLUSION Perioperative melatonin or melatonin agonist treatment suppressed POD without severe adverse events, particularly at higher doses, during the early postoperative period, and after cardiopulmonary surgery.
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Affiliation(s)
- Hye Won Shin
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Ji Su Kwak
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Yoon Ji Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Ansan Hospital, Gyeonggi-do Province, Republic of Korea
| | - Jae Woo Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Hae Sun You
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Hyun Ju Shin
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Yoo Kyung Jang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
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Ekambaram V, Owens J. Medications Used for Pediatric Insomnia. Psychiatr Clin North Am 2024; 47:87-101. [PMID: 38302215 DOI: 10.1016/j.psc.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Pediatric insomnia can affect physical and mental health and cause cognitive deficits, social deficits and decrease quality of life. There are no Food and Drug Administration approved medications approved for pediatric insomnia. Pharmacologic interventions derive mostly from adult data or pediatric case reports. This review focuses on Food and Drug Administration approved prescription drugs (in adults), over-the-counter drugs, and off-label pediatric insomnia drugs. This review helps the clinician learn general principles, practice guidelines, and pharmacologic considerations for medication selection in the pediatric population. Pharmacologic management should be considered in combination with behavior therapy, which is proven to have long-lasting outcomes.
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Affiliation(s)
- Vijayabharathi Ekambaram
- Department of Psychiatry, University of Central Florida, HCA Florida Healthcare Program, 8383 N. Davis Hwy, Pensacola, FL 32514, USA.
| | - Judith Owens
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Ou-yang CL, Ma LB, Wu XD, Ma YL, Liu YH, Tong L, Li H, Lou JS, Cao JB, Mi WD. Association of sleep quality on the night of operative day with postoperative delirium in elderly patients: A prospective cohort study. Eur J Anaesthesiol 2024; 41:226-233. [PMID: 38230449 PMCID: PMC10842671 DOI: 10.1097/eja.0000000000001952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND Sleep disturbances in the peri-operative period have been associated with adverse outcomes, including postoperative delirium (POD). However, research on sleep quality during the immediate postoperative period is limited. OBJECTIVES This study aimed to investigate the association between sleep quality on the night of the operative day assessed using the Sleep Quality Numeric Rating Scale (SQ-NRS), and the incidence of POD in a large cohort of surgical patients. DESIGN A prospective cohort study. SETTING A tertiary hospital in China. PATIENTS This study enrolled patients aged 65 years or older undergoing elective surgery under general anaesthesia. The participants were categorised into the sleep disturbance and no sleep disturbance groups according to their operative night SQ-NRS. MAIN OUTCOME MEASURES The primary outcome was delirium incidence, whereas the secondary outcomes included acute kidney injury, stroke, pulmonary infection, cardiovascular complications and all-cause mortality within 1 year postoperatively. RESULTS In total, 3072 patients were included in the analysis of this study. Among them, 791 (25.72%) experienced sleep disturbances on the night of operative day. Patients in the sleep disturbance group had a significantly higher risk of developing POD (adjusted OR 1.43, 95% CI 1.11 to 1.82, P = 0.005). Subgroup analysis revealed that age 65-75 years; male sex; ASA III and IV; haemoglobin more than 12 g l -1 ; intra-operative hypotension; surgical duration more than 120 min; and education 9 years or less were significantly associated with POD. No interaction was observed between the subgroups. No significant differences were observed in the secondary outcomes, such as acute kidney injury, stroke, pulmonary infection, cardiovascular complications and all-cause mortality within 1 year postoperatively. CONCLUSIONS The poor subjective sleep quality on the night of operative day was independently associated with increased POD risk, especially in certain subpopulations. Optimising peri-operative sleep may reduce POD. Further research should investigate potential mechanisms and causal relationships. TRIAL REGISTRY chictr.org.cn: ChiCTR1900028545.
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Ishibashi Y, Sogawa R, Ogata K, Matsuoka A, Yamada H, Murakawa-Hirachi T, Mizoguchi Y, Monji A, Shimanoe C. Association Between Antidiabetic Drugs and Delirium: A Study Based on the Adverse Drug Event Reporting Database in Japan. Clin Drug Investig 2024; 44:115-120. [PMID: 38135802 DOI: 10.1007/s40261-023-01337-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND AND OBJECTIVE Several associations between diabetes mellitus and delirium have been reported; however, they have been inconsistent, and evidence on the effects of antidiabetic medications on delirium is also limited. This study aimed to investigate whether the use of antidiabetic drugs is a risk factor for delirium development. METHODS Using the Japanese Adverse Event Reporting Database, we analyzed 662,899 reports between 2004 and 2022. Reporting odds ratios (RORs) and 95% confidence intervals (CIs) for delirium associated with diabetes and using each antidiabetic medication were calculated after adjusting for potential confounders. RESULTS Overall, 8892 of the reports analyzed were associated with delirium. A comparison of the incidence of delirium between patients with and without diabetes showed no significant difference, with 1.34% in patients without diabetes and 1.37% in those with diabetes. In each antidiabetic medication, signals for delirium were detected for sulfonylurea (crude ROR, 1.35; 95% CI 1.21-1.51) and insulin (crude ROR, 1.28; 95% CI 1.13-1.44). These results were maintained even after adjusting for factors with potential confounders (sulfonylurea: adjusted ROR, 1.75; 95% CI 1.54-2.00, insulin: adjusted ROR, 1.35; 95% CI 1.20-1.54). CONCLUSIONS Our results suggest no association between diabetes and delirium; however, using sulfonylurea and insulin may be associated with delirium development. Nonetheless, these findings should be validated in future studies.
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Affiliation(s)
- Yukiko Ishibashi
- Department of Pharmacy, Saga University Hospital, 5-1-1, Nabeshima, Saga, 849-8501, Japan
| | - Rintaro Sogawa
- Department of Pharmacy, Saga University Hospital, 5-1-1, Nabeshima, Saga, 849-8501, Japan.
| | - Kenji Ogata
- Department of Pharmacy, Saga University Hospital, 5-1-1, Nabeshima, Saga, 849-8501, Japan
| | - Ayaka Matsuoka
- Department of Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Haruna Yamada
- Faculty of Medicine, Institute of Nursing, Saga University, Saga, Japan
| | | | - Yoshito Mizoguchi
- Department of Psychiatry, Faculty of Medicine, Saga University, Saga, Japan
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Mei X, Liu YH, Han YQ, Zheng CY. Risk factors, preventive interventions, overlapping symptoms, and clinical measures of delirium in elderly patients. World J Psychiatry 2023; 13:973-984. [PMID: 38186721 PMCID: PMC10768493 DOI: 10.5498/wjp.v13.i12.973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/14/2023] [Accepted: 10/30/2023] [Indexed: 12/19/2023] Open
Abstract
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.
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Affiliation(s)
- Xi Mei
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, China
| | - Yue-Hong Liu
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, China
| | - Ya-Qing Han
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, China
| | - Cheng-Ying Zheng
- Department of Psychiatry, Ningo Kangning Hospital, Ningbo 315201, Zhejiang Province, China
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Kinouchi M, Mihara T, Taguri M, Ogura M. The Efficacy of Ramelteon to Prevent Postoperative Delirium After General Anesthesia in the Elderly: A Double-Blind, Randomized, Placebo-Controlled Trial. Am J Geriatr Psychiatry 2023; 31:1178-1189. [PMID: 37567839 DOI: 10.1016/j.jagp.2023.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE Postoperative delirium is common and serious in elderly patients. Several drugs have been proposed as potential prophylactic agents for postoperative delirium. Studies on melatonin receptor agonists showed heterogeneity in age, cognitive function, anesthesia, surgery, interventions, methodologies for assessing outcomes, and results. Our objective was to examine the effect of ramelteon to prevent postoperative delirium in elderly patients, including those with dementia. DESIGN A stratified, double-blind, randomized, placebo-controlled trial (UMIN000028436, jRCTs031180054). SETTING Tertiary medical center. PARTICIPANTS Patients aged older than or equal to 65 years undergoing elective surgery under general anesthesia. INTERVENTION Ramelteon (8 mg orally) or placebo (lactose) for six nights (the preoperative night and five consecutive nights from postoperative day 1 to 5) at around 9 P.M. MEASUREMENTS Patients were screened for postoperative delirium using the Confusion Assessment Method for the Intensive Care Unit twice daily until the sixth postoperative day. Patients with positive results were referred to a consultant psychiatrist to establish the diagnosis of delirium. RESULTS A total of 108 patients were randomly assigned to receive ramelteon (n = 55) or placebo (n = 53). Most of the patients' characteristics were reasonably well-balanced between the two groups. The stratified log-rank test showed no significant difference in preventing postoperative delirium between ramelteon and placebo (χ2 = 0.30, degrees of freedom = 1, p = 0.60). The Cox proportional hazard ratio for ramelteon compared to placebo was 1.40 (95% confidence interval: 0.40-4.85, χ2 for likelihood ratio test = 0.29, degrees of freedom = 1, p = 0.60). CONCLUSION There was no significant difference in the incidence of postoperative delirium between ramelteon and placebo after general anesthesia in elderly patients.
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Affiliation(s)
- Mariko Kinouchi
- Healthy Aging Innovation Center (MK), Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan; Department of Biostatistics (MK), School of Medicine, Yokohama City University, Yokohama, Japan; Department of Anesthesiology (MK), Keiyu Hospital, Yokohama, Japan.
| | - Takahiro Mihara
- Department of Health Data Science (TM), Graduate School of Data Science, Yokohama City University, Yokohama, Japan; Department of Anesthesiology (TM), School of Medicine, Yokohama City University, Yokohama, Japan
| | - Masataka Taguri
- Department of Health Data Science (MT), Tokyo Medical University, Tokyo, Japan
| | - Makoto Ogura
- Department of Anesthesiology (MO), Saitama Cancer Center, Saitama, Japan
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Zhang D, Jia X, Lin D, Ma J. Melatonin or its analogs as premedication to prevent emergence agitation in children: a systematic review and meta-analysis. BMC Anesthesiol 2023; 23:392. [PMID: 38037000 PMCID: PMC10687973 DOI: 10.1186/s12871-023-02356-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 11/22/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Emergence agitation (EA) is a prevalent complication in children following general anesthesia. Several studies have assessed the relationship between melatonin or its analogs and the incidence of pediatric EA, yielding conflicting results. This meta-analysis aims to assess the effects of premedication with melatonin or its analogs on preventing EA in children after general anesthesia. METHODS PubMed, EMBASE, the Cochrane Library, ProQuest Dissertations & Theses Global, Web of Science, CNKI, Wanfang Data, clinicaltrials.gov, and WHO International Clinical Trials Registry Platform were searched until 25 November 2022. We included randomized controlled trials that assessed EA in patients less than 18 years old who underwent general anesthesia. We excluded studies that did not use a specific evaluation to assess EA. RESULTS Nine studies (951 participants) were included in this systematic review. Melatonin significantly reduced the incidence of EA compared with placebos (risk ratio 0.40, 95% CI 0.26 to 0.61, P < 0.01) and midazolam (risk ratio 0.48, 95% CI 0.32 to 0.73, P < 0.01). Dexmedetomidine remarkably decreased the incidence of EA compared with melatonin (risk ratio 2.04, 95% CI 1.11 to 3.73, P = 0.02). CONCLUSIONS Melatonin premedication significantly decreases the incidence of EA compared with placebos and midazolam. Dexmedetomidine premedication has a stronger effect than melatonin in preventing EA. Nevertheless, further studies are warranted to reinforce and validate the conclusion on the efficacy of melatonin premedication in mitigating EA in pediatric patients.
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Affiliation(s)
- Dongni Zhang
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Xiaotong Jia
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Duomao Lin
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Jun Ma
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China.
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13
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Nagata C, Hata M, Miyazaki Y, Masuda H, Wada T, Kimura T, Fujii M, Sakurai Y, Matsubara Y, Yoshida K, Miyagawa S, Ikeda M, Ueno T. Development of postoperative delirium prediction models in patients undergoing cardiovascular surgery using machine learning algorithms. Sci Rep 2023; 13:21090. [PMID: 38036664 PMCID: PMC10689441 DOI: 10.1038/s41598-023-48418-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 11/27/2023] [Indexed: 12/02/2023] Open
Abstract
Associations between delirium and postoperative adverse events in cardiovascular surgery have been reported and the preoperative identification of high-risk patients of delirium is needed to implement focused interventions. We aimed to develop and validate machine learning models to predict post-cardiovascular surgery delirium. Patients aged ≥ 40 years who underwent cardiovascular surgery at a single hospital were prospectively enrolled. Preoperative and intraoperative factors were assessed. Each patient was evaluated for postoperative delirium 7 days after surgery. We developed machine learning models using the Bernoulli naive Bayes, Support vector machine, Random forest, Extra-trees, and XGBoost algorithms. Stratified fivefold cross-validation was performed for each developed model. Of the 87 patients, 24 (27.6%) developed postoperative delirium. Age, use of psychotropic drugs, cognitive function (Mini-Cog < 4), index of activities of daily living (Barthel Index < 100), history of stroke or cerebral hemorrhage, and eGFR (estimated glomerular filtration rate) < 60 were selected to develop delirium prediction models. The Extra-trees model had the best area under the receiver operating characteristic curve (0.76 [standard deviation 0.11]; sensitivity: 0.63; specificity: 0.78). XGBoost showed the highest sensitivity (AUROC, 0.75 [0.07]; sensitivity: 0.67; specificity: 0.79). Machine learning algorithms could predict post-cardiovascular delirium using preoperative data.Trial registration: UMIN-CTR (ID; UMIN000049390).
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Affiliation(s)
- Chie Nagata
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Masahiro Hata
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yuki Miyazaki
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hirotada Masuda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tamiki Wada
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tasuku Kimura
- SANKEN (The Institution of Scientific and Industrial Research), Osaka University, Ibaraki, Osaka, Japan
| | - Makoto Fujii
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yasushi Sakurai
- SANKEN (The Institution of Scientific and Industrial Research), Osaka University, Ibaraki, Osaka, Japan
| | - Yasuko Matsubara
- SANKEN (The Institution of Scientific and Industrial Research), Osaka University, Ibaraki, Osaka, Japan
| | - Kiyoshi Yoshida
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Manabu Ikeda
- Department of Psychiatry, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takayoshi Ueno
- Division of Health Sciences, Osaka University Graduate School of Medicine, 1-7 Yamadaoka, Suita, Osaka, 565-0871, Japan
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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14
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Wada M, Yasuda H, Nakajima S, Etani T, Miura A, Asada S, Yoshida K, Noda Y, Takeuchi H. Efficacy and moderators of prevention and treatment of delirium with melatonin receptor agonists: A systematic review and meta-analysis of randomized controlled trials. Gen Hosp Psychiatry 2023; 85:71-79. [PMID: 37826886 DOI: 10.1016/j.genhosppsych.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE Delirium is a complex and heterogeneous condition that significantly affects patient outcome. This study aimed to conduct a systematic review and meta-analysis to investigate the effects of melatonin and melatonin receptor agonists (MRAs) on delirium prevention and treatment. METHOD Randomized controlled studies, using MRAs as an intervention and placebo as a control were included. We conducted meta-analyses with random-effects model and trial sequential analysis. RESULTS A total of 33 studies involving 4850 participants were included. The meta-analysis revealed a significant preventive effect of MRAs on delirium (risk ratio = 0.65, p < 0.01), while no significant therapeutic effect was observed. Additionally, MRAs were associated with a significant reduction in mortality rate (risk ratio = 0.90, p = 0.02) in delirium prevention studies. Furthermore, subgroup analyses revealed that assessment scales and the frequency of delirium detection may be significant moderators of the delirium-preventive efficacy of MRAs. CONCLUSION This study provides evidence of the potential effects of MRAs in preventing delirium and reducing mortality. Further research is required to elucidate the therapeutic potential of MRAs for delirium and identify specific patient populations that may benefit from this agent.
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Affiliation(s)
- Masataka Wada
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hideaki Yasuda
- Department of Psychiatry, Sekito Hospital, Shimane, Japan
| | - Shinichiro Nakajima
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Multimodal Imaging Group, Research Imaging Centre, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Takahide Etani
- School of Medicine, College of Medical, Pharmaceutical, and Health, Kanazawa University, Kanazawa, Japan; Graduate School of Media and Governance, Keio University, Fujisawa, Japan; Advanced Research Center for Human Sciences, Waseda University, Tokorozawa, Japan
| | - Akihiko Miura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Asada
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Kazunari Yoshida
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; Tanenbaum Centre for Pharmacogenetics, Neurogenetics Section, Molecular Brain Sciences Research Department, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada; Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Yoshihiro Noda
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyoshi Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan.
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15
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Asai Y, Yanagawa T, Takahashi M. Effect of pharmacist-led intervention protocol on preventing postoperative delirium after elective cardiovascular surgery. PLoS One 2023; 18:e0292786. [PMID: 37824500 PMCID: PMC10569577 DOI: 10.1371/journal.pone.0292786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/08/2023] [Indexed: 10/14/2023] Open
Abstract
Postoperative delirium (PD) is an acute brain dysfunction, with a particularly high incidence after cardiovascular surgery. Pharmacist-led interventions show limited evidence in attenuating PD in cardiovascular surgery. In this retrospective cohort study, we aimed to clarify the risk factors of PD for cardiovascular surgery focused on pharmacotherapy and elucidate the effect of pharmacist-led intervention on the PD attenuation rate based on protocol-based pharmaceutical management (PBPM). This study included 142 adult patients who underwent elective valve replacement or valvuloplasty. The risk factors for PD were investigated using multivariate logistic regression analysis. Taking risk factors into consideration, a protocol was developed to discontinue benzodiazepines prescriptions by ward pharmacists, and replace with ramelteon and suvorexant if all the following factors apply: 1) number of medications ≥ 6 drugs, 2) number of doses to take ≥ 4 times, and 3) regular use of benzodiazepines or insomnia. Subsequently, the PD rate was compared during a period of two years and 6 months between the pre-PBPM (n = 39) and post-PBPM (n = 62). The PD rate for elective valve replacement or valvuloplasty was 25% (35/142). The adjusted odds ratio for polypharmacy was 3.3 (95% confidence interval: 1.2-8.9, p = 0.016), suggesting that preoperative risk assessment may be essential for patients with polypharmacy. The PD rate significantly decreased to 13% (8/62) in the post-PBPM group compared with 33% (13/39) in the pre-PBPM group (p = 0.014). There was a significant decrease in benzodiazepines use in post-PBPM compared with pre-PBPM (p = 0.026); however, the rate of ramelteon and orexin receptor antagonists use increased by PBPM introduction (p < 0.001). Although the present PBPM still requires further modification, it is simple and potentially useful for pharmacists to assess the risk of patients undergoing any elective cardiovascular surgery.
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Affiliation(s)
- Yuki Asai
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, Hisaimyojin, Tsu, Mie, Japan
| | - Tatsuki Yanagawa
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, Hisaimyojin, Tsu, Mie, Japan
| | - Masaaki Takahashi
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, Hisaimyojin, Tsu, Mie, Japan
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16
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Mayanagi S, Haneda R, Inoue M, Ishii K, Tsubosa Y. Ramelteon and suvorexant for postoperative delirium in elderly patients with esophageal cancer. Esophagus 2023; 20:635-642. [PMID: 37561254 DOI: 10.1007/s10388-023-01019-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/19/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND There is no clear evidence on the prevention of postoperative delirium with pharmacotherapy in elderly patients with esophageal cancer. This retrospective study aimed to evaluate the efficacy of ramelteon and suvorexant in preventing postoperative delirium in this patient group. METHODS Data on 251 patients who received radical esophagectomy for thoracic esophageal cancer were collected from January 2010 to September 2021. In total, 74 patients did not receive preventive intervention, and 177 received ramelteon and suvorexant. After propensity score matching, the rate of postoperative delirium was compared between the two groups. RESULTS Seventy-two well-balanced patients in each group demonstrated similar clinical and pathological characteristics. The mean ages of the intervention and control groups were 70.8 and 70.3 years, respectively. All the patients underwent McKeown esophagectomy, and in the volume of intraoperative blood loss or operative time did not significantly differ between the two groups. The incidence rates of postoperative hyperactive delirium were 7% (5/72) in the intervention group and 32% (23/72) in the control group (p < 0.001). No severe adverse event potentially attributable to the intervention drug was observed. The multivariate analysis showed that the use of ramelteon and suvorexant was the only independent protective factor against postoperative delirium (hazard ratio 0.157, 95% CI 0.055-0.448, p < 0.001). CONCLUSIONS Ramelteon and suvorexant may play an important role in reducing postoperative delirium in elderly patients with esophageal cancer.
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Affiliation(s)
- Shuhei Mayanagi
- Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, 1004 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Ryoma Haneda
- Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu City , Shizuoka, Japan
| | - Masazumi Inoue
- Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, 1004 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kenjiro Ishii
- Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, 1004 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Yasuhiro Tsubosa
- Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, 1004 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
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17
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Eschbach E, Wang J. Sleep and critical illness: a review. Front Med (Lausanne) 2023; 10:1199685. [PMID: 37828946 PMCID: PMC10566646 DOI: 10.3389/fmed.2023.1199685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/07/2023] [Indexed: 10/14/2023] Open
Abstract
Critical illness and stays in the Intensive Care Unit (ICU) have significant impact on sleep. Poor sleep is common in this setting, can persist beyond acute critical illness, and is associated with increased morbidity and mortality. In the past 5 years, intensive care clinical practice guidelines have directed more focus on sleep and circadian disruption, spurring new initiatives to study and improve sleep complications in the critically ill. The global SARS-COV-2 (COVID-19) pandemic and dramatic spikes in patients requiring ICU level care also brought augmented levels of sleep disruption, the understanding of which continues to evolve. This review aims to summarize existing literature on sleep and critical illness and briefly discuss future directions in the field.
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Affiliation(s)
- Erin Eschbach
- Division of Pulmonary, Critical Care, and Sleep, Mount Sinai Hospital, New York, NY, United States
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18
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Faeder M, Hale E, Hedayati D, Israel A, Moschenross D, Peterson M, Peterson R, Piechowicz M, Punzi J, Gopalan P. Preventing and treating delirium in clinical settings for older adults. Ther Adv Psychopharmacol 2023; 13:20451253231198462. [PMID: 37701890 PMCID: PMC10493062 DOI: 10.1177/20451253231198462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
Delirium is a serious consequence of many acute or worsening chronic medical conditions, a side effect of medications, and a precipitant of worsening functional and cognitive status in older adults. It is a syndrome characterized by fluctuations in cognition and impaired attention that develops over a short period of time in response to an underlying medical condition, a substance (prescribed, over the counter, or recreational), or substance withdrawal and can be multi-factorial. We present a narrative review of the literature on nonpharmacologic and pharmacologic approaches to prevention and treatment of delirium with a focus on older adults as a vulnerable population. Older adult patients are most at risk due to decreasing physiologic reserves, with delirium rates of up to 80% in critical care settings. Presentation of delirium can be hyperactive, hypoactive, or mixed, making identification and study challenging as patients with hypoactive delirium are less likely to come to attention in an inpatient or long-term care setting. Studies of delirium focus on prevention and treatment with nonpharmacological or medication interventions, with the preponderance of evidence favoring multi-component nonpharmacological approaches to prevention as the most effective. Though use of antipsychotic medication in delirium is common, existing evidence does not support routine use, showing no clear benefit in clinically significant outcome measures and with evidence of harm in some studies. We therefore suggest that antipsychotics be used to treat agitation, psychosis, and distress associated with delirium at the lowest effective doses and shortest possible duration and not be considered a treatment of delirium itself. Future studies may clarify the use of other agents, such as melatonin and melatonin receptor agonists, alpha-2 receptor agonists, and anti-epileptics.
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Affiliation(s)
- Morgan Faeder
- University of Pittsburgh School of Medicine, 3811 O’Hara Street, Pittsburgh, PA 15261, USA
| | - Elizabeth Hale
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Daniel Hedayati
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alex Israel
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Melanie Peterson
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ryan Peterson
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mariel Piechowicz
- University of Pittsburgh Medical Center Health System, Pittsburgh, PA, USA
| | - Jonathan Punzi
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Priya Gopalan
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Mukundarajan R, Soni KD, Trikha A. Prophylactic Melatonin for Delirium in Intensive Care Unit: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2023; 27:675-685. [PMID: 37719343 PMCID: PMC10504656 DOI: 10.5005/jp-journals-10071-24529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 08/10/2023] [Indexed: 09/19/2023] Open
Abstract
Introduction Delirium, being a common disorder among critically ill patients, has a reported incidence ranging 45-83% in the intensive care unit (ICU) population. The prophylactic use of melatonin and melatonergics has been shown to have a positive effect in reducing the incidence of delirium in many clinical trials. Our study was thus proposed to find out the role of melatonin on the incidence and severity of ICU delirium, ICU and hospital length of stay (LOS), requirement, duration of mechanical ventilation, and ICU mortality. Methodology A systematic search of various databases was performed to find out the trials which compare melatonin with a placebo or standard therapy for delirium prevention with the results conveyed as mean differences (MDs) or risk ratios. The statistical software, Review Manager (RevMan, version 5.4), was used for data synthesis. Results Twelve studies were included in the meta-analysis. Prophylactic administration of melatonin or ramelteon was not associated with a statistically significant reduction in the incidence of delirium (odds ratio [OR] 0.63; confidence interval [CI]: 0.60, 1.32; p = 0.22), the severity of delirium (MD: 0.22; 95% CI: From -1.36 to 1.81; p = 0.78), ICU LOS (MD: 0.05; 95% CI: From -0.65 to 0.75; p = 0.89), hospital LOS (MD: -1.46; 95% CI: From -4.50 to -1.59; p = 0.35), need for mechanical ventilation (OR: 0.74, 95% CI: 0.38-1.44; p = 0.37), and ICU mortality (MD: 0.78; 95% CI: 0.56; 1.11; p = 0.62). However, a significant reduction in the duration of mechanical ventilation (MD: -0.85; 95% CI: From -1.64 to -0.06; p = 0.03) was found. Conclusion Our meta-analysis suggests that melatonin when given prophylactically has no significant role in reducing the incidence and severity of delirium, ICU and hospital LOS, need for mechanical ventilation, duration of mechanical ventilation, and ICU mortality. Further studies are warranted. How to cite this article Mukundarajan R, Soni KD, Trikha A. Prophylactic Melatonin for Delirium in Intensive Care Unit: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2023;27(9):675-685.
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Affiliation(s)
- Ramkumar Mukundarajan
- Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Kapil Dev Soni
- Department of Critical and Intensive Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Anjan Trikha
- Department of Anesthesia and Perioperative Care, School of Medicine, University of California, San Francisco, California, United States of America
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20
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Duan Y, Yang Y, Zhu W, Wan L, Wang G, Yue J, Bao Q, Shao J, Wan X. Melatonin intervention to prevent delirium in the intensive care units: a systematic review and meta-analysis of randomized controlled trials. Front Endocrinol (Lausanne) 2023; 14:1191830. [PMID: 37564987 PMCID: PMC10410466 DOI: 10.3389/fendo.2023.1191830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/07/2023] [Indexed: 08/12/2023] Open
Abstract
Objective To determine the preventive effect of melatonin on delirium in the intensive care units. Methods We conducted a systematic search of the PubMed, Cochrane Library, Science, Embase, and CNKI databases, with retrieval dates ranging from the databases' inception to September 2022. Controlled trials on melatonin and placebo for preventing delirium in the intensive care units were included. The meta-analysis was performed using Review Manager software (version 5.3) and Stata software (version 14.0). Results Six studies involving 2374 patients were included in the meta-analysis. The results of the meta-analysis showed that melatonin did not reduce the incidence of delirium in ICU patients (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.46 to 1.12; p = 0.14). There was a strong hetero-geneity between the selected studies (I2 = 74%). Subgroup analysis results showed that melatonin reduced the incidence of delirium in cardiovascular care unit (CCU) patients (OR: 0.52; 95% CI: 0.37 to 0.73; p=0.0001), but did not in general intensive care unit (GICU) patients (OR: 1.14; 95% CI: 0.86 to 1.50; p=0.35). In terms of the secondary outcomes, there were no significant differences in all-cause mortality (OR: 0.85; 95% CI: 0.66 to 1.09; p=0.20), length of ICU stay (mean difference [MD]: 0.33; 95% CI: -0.53 to 1.18; p=0.45), or length of hospital stay (MD: 0.51; 95% CI: -1.17 to 2.19; p=0.55). Conclusion Melatonin reduced the incidence of delirium in CCU patients, but did not significantly reduce the incidence of delirium in GICU patients. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier CRD42022367665.
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Affiliation(s)
- Yushan Duan
- Department of Critical Care Medicine, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Yuan Yang
- Department of Anesthesiology, The First Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Weihua Zhu
- Department of Critical Care Medicine, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Linjun Wan
- Department of Critical Care Medicine, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Gang Wang
- Department of Critical Care Medicine, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Jinxi Yue
- Department of Critical Care Medicine, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Qi Bao
- Department of Critical Care Medicine, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Jianlin Shao
- Department of Anesthesiology, The First Affiliated Hospital, Kunming Medical University, Kunming, China
| | - Xiaohong Wan
- Department of Critical Care Medicine, The Second Affiliated Hospital, Kunming Medical University, Kunming, China
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Rodrigues V, Batista S, Heringer DL, Nunes JC, Anand A, Barradas PC. Comment on Yang et al., 2020: Melatonergic agents in the prevention of delirium: A network meta-analysis of randomized controlled trials. Sleep Med Rev 2023; 70:101802. [PMID: 37354761 DOI: 10.1016/j.smrv.2023.101802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 06/26/2023]
Abstract
An analysis of delirium prevention considering only older adults is essential. Delirium markedly impacts the older adult population, as it is associated with inpatient occurrence rates from 14% to 56% and hospital mortality rates from 25% to 33% [2]. Ageing comes with a cumulative decline in physiological systems and is a relevant risk factor for chronic diseases [3,4]. Delirium causes in older adults can be multifactorial, including underlying medical conditions, medications, and environmental factors. Therefore, it is vital for healthcare providers to monitor for delirium symptoms in older adults and to implement appropriate interventions, such as addressing underlying medical conditions and addressing possible triggers [5]. Likewise, it is reasonable to think that eventual delirium preventive solutions for older patients would differentiate from the general population.
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Affiliation(s)
- Victor Rodrigues
- Faculty of Medical Sciences, Rio de Janeiro State University, Rio de Janeiro, RJ, Brazil.
| | - Sávio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Julio Cesar Nunes
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Akhil Anand
- Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA; Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH, USA
| | - Penha Cristina Barradas
- Department of Pharmacology and Psychobiology, Instituto de Biologia Roberto Alcantara Gomes, Rio de Janeiro State University, Rio de Janeiro, RJ, Brazil
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22
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Yang CP, Tseng PT, Yang CC, Tsai IJ, Su KP. Delirium prevention with age consideration-Reply to "Comment on Yang et al., 2020: Melatonergic agents in the prevention of delirium: A network meta-analysis of randomized controlled trials". Sleep Med Rev 2023; 70:101803. [PMID: 37336066 DOI: 10.1016/j.smrv.2023.101803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/21/2023] [Indexed: 06/21/2023]
Affiliation(s)
- Chun-Pai Yang
- Department of Neurology, Kuang Tien General Hospital, Taichung, Taiwan; Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Ping-Tao Tseng
- WinShine Clinics in Specialty of Psychiatry, Kaohsiung, Taiwan; Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung, Taiwan; Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Cheng-Chia Yang
- Department of Healthcare Administration, Asia University, Taichung, Taiwan
| | - I-Ju Tsai
- Department of Medical Research, Kuang Tien General Hospital, Taichung, Taiwan; Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Kuan-Pin Su
- Mind-Body Interface Research Center (MBI-Lab), China Medical University Hospital, Taichung, Taiwan; College of Medicine, China Medical University, Taichung, Taiwan.
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Otani K, Fukushima H, Matsuishi K. COVID-19 delirium and encephalopathy: Pathophysiology assumed in the first 3 years of the ongoing pandemic. BRAIN DISORDERS 2023; 10:100074. [PMID: 37056914 PMCID: PMC10076074 DOI: 10.1016/j.dscb.2023.100074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 04/15/2023] Open
Abstract
Background The coronavirus disease (COVID-19) continues to spread worldwide. It has a high rate of delirium, even in young patients without comorbidities. Infected patients required isolation because of the high infectivity and virulence of COVID-19. The high prevalence of delirium in COVID-19 primarily results from encephalopathy and neuroinflammation caused by acute respiratory distress syndrome (ARDS)-associated cytokine storm. Acute respiratory distress syndrome has been linked to delirium and psychotic symptoms in the subacute phase (4 to 12 weeks), termed post-acute COVID-19 syndrome (PACS), and to brain fog, cognitive dysfunction, and fatigue, termed "long COVID," which persists beyond 12 weeks. However, no review article that mentions "COVID-19 delirium" have never been reported. Basic Procedures This narrative review summarizes data on delirium associated with acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and related neurological symptoms of persistent post-infection illness (PACS or long COVID) after persistence of cognitive dysfunction. Thus, we describe the pathophysiological hypothesis of COVID-19 delirium and its continuation as long COVID. This review also describes the treatment of delirium complicated by COVID-19 pneumonia. Main Findings SARS-CoV-2 infection is associated with encephalopathy and delirium. An association between COVID-19 infection and Alzheimer's disease has been suggested, and studies are being conducted from multiple facets including genetics, cytology, and postmortem study. Principal Conclusions This review suggests that COVID-19 has important short and long-term neuropsychiatric effects. Several hypotheses have been proposed that highlight potential neurobiological mechanisms as causal factors, including neuronal-inflammatory pathways by cytokine storm and cellular senescence, and chronic inflammation.
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Affiliation(s)
- Kyohei Otani
- Department of Psychiatry, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
- Department of Psychiatry, Kakogawa Central City Hospital, 439, Kakogawa-cho honmachi, Kakogawa City, Hyogo, 675-8611, Japan
| | - Haruko Fukushima
- Department of Psychiatry, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Kunitaka Matsuishi
- Department of Psychiatry, Kobe City Medical Center General Hospital, 2-1-1, Minatojima Minamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
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24
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Oda S, Takechi K, Hirai S, Takatori S, Otsuka T. Association between nocturnal falls and hypnotic drug use in older patients at acute care hospitals. Eur J Clin Pharmacol 2023; 79:753-758. [PMID: 37010536 DOI: 10.1007/s00228-023-03485-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/23/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE Although hypnotic drug use is a known risk factor for falls, few reports have analyzed fall risk associated with individual hypnotic drugs after adjusting for confounding factors. While it is recommended that benzodiazepine receptor agonists not be prescribed for older adults, it is unknown whether melatonin receptor agonists and orexin receptor antagonists are safe in this population. Here, we aimed to assess the influence of various hypnotic drugs on fall risk in older patients admitted to acute care hospitals. METHODS We investigated the relationship between nocturnal falls and sleeping pill use in 8,044 hospitalized patients aged > 65 years. We used a propensity score matching method to homogenize characteristics of patients with and without nocturnal falls (n = 145 patients per group) using 24 extracted factors (excluding hypnotic drugs) as covariates. RESULTS Our analysis of fall risk for each hypnotic drug revealed that benzodiazepine receptor agonists were the only drugs significantly associated with falls, suggesting that use of the drugs is a risk factor for falls in older adults (p = 0.003). In addition, a multivariate analysis of 24 selected factors, excluding hypnotic drugs, revealed that patients with advanced recurrent malignancies were at greatest risk of experiencing falls (OR: 2.62; 95% CI: 1.23-5.60; p = 0.013). CONCLUSION Benzodiazepine receptor agonists should be avoided in older hospitalized patients since they increase fall risk, with melatonin receptor agonists and orexin receptor antagonists used instead. Particularly, fall risk associated with hypnotic drugs should be considered in patients with advanced recurrent malignancies.
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Affiliation(s)
- Shinji Oda
- Department of Pharmacy, Matsuyama Shimin Hospital, Matsuyama, Japan
| | - Kenshi Takechi
- Department of Drug Information Analysis, College of Pharmaceutical Sciences, Matsuyama University, 4-2 Bunkyo-cho, Ehime, 790-8578, Matsuyama, Japan.
| | - Satoru Hirai
- Department of Rehabilitation, Matsuyama Shimin Hospital, Matsuyama, Japan
| | - Shingo Takatori
- Department of Drug Information Analysis, College of Pharmaceutical Sciences, Matsuyama University, 4-2 Bunkyo-cho, Ehime, 790-8578, Matsuyama, Japan
| | - Takashi Otsuka
- Department of Pharmacy, Matsuyama Shimin Hospital, Matsuyama, Japan
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25
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Knauert MP, Ayas NT, Bosma KJ, Drouot X, Heavner MS, Owens RL, Watson PL, Wilcox ME, Anderson BJ, Cordoza ML, Devlin JW, Elliott R, Gehlbach BK, Girard TD, Kamdar BB, Korwin AS, Lusczek ER, Parthasarathy S, Spies C, Sunderram J, Telias I, Weinhouse GL, Zee PC. Causes, Consequences, and Treatments of Sleep and Circadian Disruption in the ICU: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2023; 207:e49-e68. [PMID: 36999950 PMCID: PMC10111990 DOI: 10.1164/rccm.202301-0184st] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
Background: Sleep and circadian disruption (SCD) is common and severe in the ICU. On the basis of rigorous evidence in non-ICU populations and emerging evidence in ICU populations, SCD is likely to have a profound negative impact on patient outcomes. Thus, it is urgent that we establish research priorities to advance understanding of ICU SCD. Methods: We convened a multidisciplinary group with relevant expertise to participate in an American Thoracic Society Workshop. Workshop objectives included identifying ICU SCD subtopics of interest, key knowledge gaps, and research priorities. Members attended remote sessions from March to November 2021. Recorded presentations were prepared and viewed by members before Workshop sessions. Workshop discussion focused on key gaps and related research priorities. The priorities listed herein were selected on the basis of rank as established by a series of anonymous surveys. Results: We identified the following research priorities: establish an ICU SCD definition, further develop rigorous and feasible ICU SCD measures, test associations between ICU SCD domains and outcomes, promote the inclusion of mechanistic and patient-centered outcomes within large clinical studies, leverage implementation science strategies to maximize intervention fidelity and sustainability, and collaborate among investigators to harmonize methods and promote multisite investigation. Conclusions: ICU SCD is a complex and compelling potential target for improving ICU outcomes. Given the influence on all other research priorities, further development of rigorous, feasible ICU SCD measurement is a key next step in advancing the field.
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26
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Yu CL, Carvalho AF, Thompson T, Tsai TC, Tseng PT, Tu YK, Yang SN, Yang FC, Chang CH, Hsu CW, Hsu TW, Liang CS. Ramelteon for delirium prevention in hospitalized patients: An updated meta-analysis and trial sequential analysis of randomized controlled trials. J Pineal Res 2023; 74:e12857. [PMID: 36726202 DOI: 10.1111/jpi.12857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 01/19/2023] [Accepted: 01/29/2023] [Indexed: 02/03/2023]
Abstract
Although ramelteon has been examined as a relatively new therapeutic option for delirium prevention, current evidence to evaluate its efficacy is limited. We conducted an updated meta-analysis and examine the reliability of existing evidence regarding the effect of ramelteon on delirium prevention in hospitalized patients. Seven major electronic databases were systematically searched to identify randomized controlled trials examining the efficacy of ramelteon in delirium prevention. Data were pooled using a frequentist-restricted maximum-likelihood random-effects model. A trial sequential analysis was performed using relative risk reduction thresholds of 50%. The primary outcome was the incidence of delirium (reported as odds ratio with 95% confidence intervals). The secondary outcomes were the days of delirium, all-cause mortality, and all-cause discontinuation. Of 187 potentially eligible studies identified, 8 placebo-controlled randomized controlled trials (n = 587) were included. This updated meta-analysis showed that ramelteon was associated with lower odds of delirium occurrence than placebo (0.50; 0.29-0.86; I2 = 17.48%). In trial sequential analysis, the effect of ramelteon across the superiority boundary when using a relative risk reduction threshold ranging from 40% to 60%. In subgroup analyses, ramelteon compared with placebo was associated with lower odds of delirium occurrence in the elderly group (k = 5; 0.28; 0.09-0.85; I2 = 27.93%) and multiple dosage group (k = 5; 0.34; 0.14-0.82; I2 = 44.24%) but not in the non-elderly and non-multiple dosage groups. When considering surgical patients and medical patients separately, ramelteon showed a trend in the treatment of delirium prevention in both groups, while these findings were not statistically significant. No significant between-group differences were found in the secondary outcomes. The current meta-analysis provides updated and reliable evidence that ramelteon, in comparison with placebo, reduces the risk of delirium among hospitalized patients.
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Affiliation(s)
- Chia-Ling Yu
- Department of Pharmacy, Chang-Gung Memorial Hospital, Linkou, Taiwan
| | - Andre F Carvalho
- IMPACT (Innovation in Mental and Physical Health and Clinical Treatment) Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, Victoria, Australia
| | - Trevor Thompson
- Centre for Chronic Illness and Ageing, University of Greenwich, London, UK
| | - Tzu-Cheng Tsai
- Department of Pharmacy, Chang-Gung Memorial Hospital, Linkou, Taiwan
| | - Ping-Tao Tseng
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung City, Taiwan
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
- Institute of Precision Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology & Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
| | - Szu-Nian Yang
- Department of Psychiatry, National Defense Medical Centre Beitou Branch, Tri-Service General Hospital, Taipei, Taiwan
- Department of Psychiatry, Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan
- Graduate Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fu-Chi Yang
- Department of Neurology, National Defense Medical Centre, Tri-Service General Hospital, Taipei, Taiwan
| | - Cheng-Ho Chang
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tien-Wei Hsu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chih-Sung Liang
- Department of Psychiatry, National Defense Medical Centre Beitou Branch, Tri-Service General Hospital, Taipei, Taiwan
- Department of Psychiatry, National Defense Medical Centre, Taipei, Taiwan
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27
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Matsuoka A, Sogawa R, Murakawa-Hirachi T, Mizoguchi Y, Monji A, Shimanoe C, Shinada K, Koami H, Sakamoto Y. Evaluation of the delirium preventive effect of dual orexin receptor antagonist (DORA) in critically ill adult patients requiring ventilation with tracheal intubation at an advanced emergency center: A single-center, retrospective, observational study. Gen Hosp Psychiatry 2023; 83:123-129. [PMID: 37182281 DOI: 10.1016/j.genhosppsych.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/01/2023] [Accepted: 03/22/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVE ICU delirium reportedly contributes to increased mortality attributed to underlying diseases, long-term cognitive decline, and increased healthcare costs. Dual orexin receptor antagonists (DORAs), suvorexant and lemborexant, have been suggested for preventing ICU delirium. Although ventilator management is a risk factor for delirium, no study has examined the efficacy of suvorexant and lemborexant in preventing delirium in critically ill patients requiring ventilation. Thus, we retrospectively evaluated the efficacy of DORA in preventing delirium in critically ill adult patients requiring ventilatory management in the emergency room. METHOD This retrospective study included patients aged ≥18 years who were admitted to the emergency room and received ventilator support between January 2015 and April 2022. The HR (95% CI) for delirium development in patients taking DORA was estimated using a Cox proportional hazards model, which was adjusted for the patient background and concomitant medications. HRs were calculated for patients taking suvorexant and those taking lemborexant using a stratified analysis. RESULTS Of the 297 patients included in the study, 67 were in the DORA group; 50 were on suvorexant and 17 were on lemborexant. The DORA group had a lower incidence of delirium than the control group (p < 0.0001). The risk of delirium was lower in the DORA group compared the control group (HR, 0.22; 95% CI 0.12-0.40).The risk of developing delirium was lower with suvorexant (HR 0.22; 95% CI 0.11-0.41) and lemborexant (HR 0.25; 95% CI 0.08-0.81). CONCLUSION DORA is a promising drug that could have the potential to prevent delirium, and its efficacy in preventing delirium should be tested in randomized controlled trials in the future.
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Affiliation(s)
- Ayaka Matsuoka
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Rintaro Sogawa
- Department of Pharmacy, Saga University Hospital, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Toru Murakawa-Hirachi
- Department of Psychiatry, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Yoshito Mizoguchi
- Department of Psychiatry, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Akira Monji
- Department of Psychiatry, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan; Wakahisa Hospital, 5-3-1, Wakahisa, Minami-ku, Fukuoka 815-0042, Japan.
| | - Chisato Shimanoe
- Department of Pharmacy, Saga University Hospital, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Kota Shinada
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan
| | - Hiroyuki Koami
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
| | - Yuichiro Sakamoto
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga Prefecture 849-8501, Japan.
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28
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Yamanashi T, Sullivan EJ, Comp KR, Nishizawa Y, Akers CC, Chang G, Modukuri M, Tran T, Anderson ZEEM, Marra PS, Crutchley KJ, Wahba NE, Iwata M, Karam MD, Noiseux NO, Cho HR, Shinozaki G. Anti-inflammatory medication use associated with reduced delirium risk and all-cause mortality: A retrospective cohort study. J Psychosom Res 2023; 168:111212. [PMID: 36963165 DOI: 10.1016/j.jpsychores.2023.111212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 02/13/2023] [Accepted: 02/28/2023] [Indexed: 03/26/2023]
Abstract
OBJECTIVE To investigate the relationship between history of anti-inflammatory medication use and delirium risk, as well as long-term mortality. METHODS In this retrospective cohort study, subjects recruited between January 2016 and March 2020 were analyzed. Information about anti-inflammatory medication use history including aspirin, NSAIDs, glucosamine, and other anti-inflammatory drugs, was collected. Logistic regression analysis investigated the relationship between anti-inflammatory medications and delirium. Log-rank analysis and cox proportional hazards model investigated the relationship between anti-inflammatory medications and one-year mortality. RESULTS The data from 1274 subjects were analyzed. The prevalence of delirium was significantly lower in subjects with NSAIDs usage (23.0%) than in those without NSAIDs usage (35.0%) (p < 0.001). Logistic regression analysis controlling for age, sex, dementia status, and hospitalization department showed that the risk of delirium tended to be reduced by a history of NSAIDs use (OR, 0.76 [95% CI, 0.55 to 1.03]). The one-year mortality in the subjects with NSAIDs (survival rate, 0.879 [95% CI, 0.845 to 0.906]) was significantly higher than in the subjects without NSAIDs (survival rate, 0.776 [95% CI, 0.746 to 0.803]) (p < 0.001). A history of NSAIDs use associated with the decreased risk of one-year mortality even after adjustment for age, sex, Charlson Comorbidity Index, delirium status, and hospitalization department (HR, 0.70 [95% CI, 0.51 to 0.96]). CONCLUSION This study suggested that NSAIDs usage was associated with decreased delirium prevalence and lower one-year mortality. The potential benefit of NSAIDs on delirium risk and mortality were shown.
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Affiliation(s)
- Takehiko Yamanashi
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Palo Alto, CA, United States of America; University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA, United States of America; Tottori University Faculty of Medicine, Department of Neuropsychiatry, Yonago, Tottori, Japan
| | - Eleanor J Sullivan
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA, United States of America
| | - Katie R Comp
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA, United States of America
| | - Yoshitaka Nishizawa
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Palo Alto, CA, United States of America; Osaka Medical and Pharmaceutical University Faculty of Medicine, Department of Neuropsychiatry, Takatsuki, Osaka, Japan
| | - Cade C Akers
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA, United States of America
| | - Gloria Chang
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA, United States of America
| | - Manisha Modukuri
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA, United States of America
| | - Tammy Tran
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA, United States of America
| | - Zoe-Ella E M Anderson
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA, United States of America
| | - Pedro S Marra
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA, United States of America
| | - Kaitlyn J Crutchley
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA, United States of America
| | - Nadia E Wahba
- University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA, United States of America
| | - Masaaki Iwata
- Tottori University Faculty of Medicine, Department of Neuropsychiatry, Yonago, Tottori, Japan
| | - Matthew D Karam
- University of Iowa Carver College of Medicine, Department of Orthopedic Surgery, Iowa City, IA, United States of America
| | - Nicolas O Noiseux
- University of Iowa Carver College of Medicine, Department of Orthopedic Surgery, Iowa City, IA, United States of America
| | - Hyunkeun R Cho
- University of Iowa College of Public Health, Department of Biostatistics, Iowa City, IA, United States of America
| | - Gen Shinozaki
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Palo Alto, CA, United States of America; University of Iowa Carver College of Medicine, Department of Psychiatry, Iowa City, IA, United States of America.
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29
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Siokas V, Roesch S, Stefanou MI, Buesink R, Wilke V, Sartor-Pfeiffer J, Adeyemi K, Poli S, Dardiotis E, Ziemann U, Feil K, Mengel A. Effects of Melatonin Administration on Post-Stroke Delirium in Patients with Intracerebral Hemorrhage. J Clin Med 2023; 12:jcm12051937. [PMID: 36902724 PMCID: PMC10004342 DOI: 10.3390/jcm12051937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
Post-stroke delirium (PSD) after intracerebral hemorrhage (ICH) is considered to be even more detrimental compared to that after ischemic stroke. Treatment options for post-ICH PSD remain limited. This study aimed at investigating to what extent prophylactic melatonin administration may have beneficial effects on post-ICH PSD. We performed a mono-centric, non-randomized, non-blinded, prospective cohort study, including 339 consecutive ICH patients admitted to the Stroke Unit (SU) from December 2015 to December 2020. The cohort consisted of ICH patients who underwent standard care (defined as the control group) and ICH patients who additionally received prophylactic melatonin (2 mg per day, at night) within 24 h of ICH onset until the discharge from the SU. The primary endpoint was post-ICH PSD prevalence. The secondary endpoints were: (i) PSD duration and (ii) the duration of SU stay. The PSD prevalence was higher in the melatonin treated cohort compared to the propensity score-matched (PSM) control group. Post-ICH PSD patients receiving melatonin had shorter SU-stay durations, and shorter PSD durations, although not statistically significant. This study shows no efficacy in limiting post-ICH PSD with preventive melatonin administration.
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Affiliation(s)
- Vasileios Siokas
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tuebingen, 72076 Tuebingen, Germany
- Department of Neurology, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41100 Larissa, Greece
| | - Sara Roesch
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tuebingen, 72076 Tuebingen, Germany
| | - Maria-Ioanna Stefanou
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tuebingen, 72076 Tuebingen, Germany
| | - Rebecca Buesink
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tuebingen, 72076 Tuebingen, Germany
| | - Vera Wilke
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tuebingen, 72076 Tuebingen, Germany
| | - Jennifer Sartor-Pfeiffer
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tuebingen, 72076 Tuebingen, Germany
| | - Kamaldeen Adeyemi
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tuebingen, 72076 Tuebingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tuebingen, 72076 Tuebingen, Germany
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41100 Larissa, Greece
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tuebingen, 72076 Tuebingen, Germany
| | - Katharina Feil
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tuebingen, 72076 Tuebingen, Germany
| | - Annerose Mengel
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, 72076 Tuebingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tuebingen, 72076 Tuebingen, Germany
- Correspondence: ; Tel.: +49-7071-29-82049
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30
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[Delirium in the context of intensive care medicine-Part 2: diagnosis, prevention and treatment]. DER NERVENARZT 2023; 94:99-105. [PMID: 36269366 DOI: 10.1007/s00115-022-01399-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 02/04/2023]
Abstract
Despite the high prevalence and the enormous medical and health economic impact, delirium syndromes are often underdiagnosed, which is mainly attributable to the high frequency of hypoactive delirium and to the frequently subtle and fluctuating psychopathology in the initial phase of delirium. These aspects also justify the need for a consequent and continuous application of standardized screening tools to detect delirium as early as possible. A multidimensional, nonpharmacological prevention of delirium is effective and still underutilized in the clinical practice. So far, there are no consensus recommendations regarding the pharmacological prevention of delirium. From a therapeutic perspective a causal approach is prioritized. Pharmacological treatment of delirium can only be considered under strict observance of specific indicators. When treating non-withdrawal-related delirium benzodiazepines should be avoided.
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31
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Actigraphy-based sleep and activity measurements in intensive care unit patients randomized to ramelteon or placebo for delirium prevention. Sci Rep 2023; 13:1450. [PMID: 36702822 PMCID: PMC9879948 DOI: 10.1038/s41598-023-28095-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 01/12/2023] [Indexed: 01/27/2023] Open
Abstract
Patients in the ICU often sleep poorly for various reasons, which may predispose to delirium. We previously conducted a clinical trial in which we tested the efficacy of ramelteon, a melatonin-receptor agonist used to treat insomnia, versus placebo, in preventing ICU delirium in patients who underwent elective pulmonary thromboendarterectomy (PTE) surgery. Here we examine sleep, activity, and circadian patterns, measured with actigraphy, to understand changes in these metrics with our intervention and in those with and without delirium. Participants wore wrist actigraphy devices while recovering post-operatively in the ICU. For sleep analysis, we extracted total sleep time and sleep fragmentation metrics over the 22:00 to 06:00 period nightly, and daytime nap duration from the daytime period (0:600 to 22:00) for each participant. For activity analyses, we extracted the following metrics: total daytime activity count (AC), maximum daytime AC, total nighttime AC, and maximum nighttime AC. Next, we performed a nonparametric circadian analysis on ACs over each 24-h day and extracted the following: interdaily stability (IS), intra-daily variability (IV), relative amplitude (RA), and low and high periods of activity (L5 and M10) as well as their start times. These metrics were compared between patients who received ramelteon versus placebo, and between patients who became delirious versus those who did not develop delirium. We additionally made comparisons between groups for daytime and nighttime light levels. No differences in sleep, activity, circadian metrics or light levels were found between drug groups. Delirious patients, when compared to those who were never delirious, had a lower IS (0.35 ± 0.16 vs. 0.47 ± 0.23; P = 0.006). Otherewise, no differences in IV, L5, M10, or RA were found between groups. L5 and M10 activity values increased significantly over the post-extubation for the whole cohort. No differences were found for daytime or nighttime light levels between groups. Overall, ramelteon did not impact sleep or circadian metrics in this cohort. Consistent with clinical experience, delirious patients had less inter-daily stability in their rest-activity rhythms. These data suggest that actigraphy might have value for individual assessment of sleep in the ICU, and for determining and detecting the impact of interventions directed at improving sleep and circadian activity rhythms in the ICU.Trial registration: REGISTERED at CLINICALTRIALS.GOV: NCT02691013. Registered on February 24, 2016 by principal investigator, Dr. Robert L. Owens.
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Aiello G, Cuocina M, La Via L, Messina S, Attaguile GA, Cantarella G, Sanfilippo F, Bernardini R. Melatonin or Ramelteon for Delirium Prevention in the Intensive Care Unit: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med 2023; 12:jcm12020435. [PMID: 36675363 PMCID: PMC9863078 DOI: 10.3390/jcm12020435] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/29/2022] [Accepted: 12/31/2022] [Indexed: 01/06/2023] Open
Abstract
Melatonin modulates the circadian rhythm and has been studied as a preventive measure against the development of delirium in hospitalized patients. Such an effect may be more evident in patients admitted to the ICU, but findings from the literature are conflicting. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). We assessed whether melatonin or ramelteon (melatonin agonist) reduce delirium incidence as compared to a placebo in ICU patients. Secondary outcomes were ICU length of stay, duration of mechanical ventilation (MV) and mortality. Estimates are presented as risk ratio (RR) or mean differences (MD) with 95% confidence interval (CI). Nine RCTs were included, six of them reporting delirium incidence. Neither melatonin nor ramelteon reduced delirium incidence (RR 0.76 (0.54, 1.07), p = 0.12; I2 = 64%), although a sensitivity analysis conducted adding other four studies showed a reduction in the risk of delirium (RR = 0.67 (95%CI 0.48, 0.92), p = 0.01; I2 = 67). Among the secondary outcomes, we found a trend towards a reduction in the duration of MV (MD -2.80 (-6.06, 0.47), p = 0.09; I2 = 94%) but no differences in ICU-LOS (MD -0.26 (95%CI -0.89, 0.37), p = 0.42; I2 = 75%) and mortality (RR = 0.85 (95%CI 0.63, 1.15), p = 0.30; I2 = 0%). Melatonin and ramelteon do not seem to reduce delirium incidence in ICU patients but evidence is weak. More studies are needed to confirm this finding.
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Affiliation(s)
- Giuseppe Aiello
- Department Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Micol Cuocina
- Department Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Luigi La Via
- Department of Anesthesiology and Intensive Care, AOU “Policlinico-San Marco”, 95123 Catania, Italy
| | - Simone Messina
- School of Specialization in Anesthesiology and Intensive Care, University “Magna Graecia”, 88100 Catanzaro, Italy
| | - Giuseppe A. Attaguile
- Department Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Giuseppina Cantarella
- Department Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Correspondence:
| | - Filippo Sanfilippo
- Department of Anesthesiology and Intensive Care, AOU “Policlinico-San Marco”, 95123 Catania, Italy
| | - Renato Bernardini
- Department Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital of Catania, 95123 Catania, Italy
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Statin Use and Delirium Risk: An Updated Systematic Review and Meta-Analysis. Am J Ther 2023:00045391-990000000-00109. [PMID: 36728521 DOI: 10.1097/mjt.0000000000001593] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/28/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Findings on the association of statin use with delirium risk are inconsistent. THE STUDY QUESTION Is statin use associated with delirium risk? STUDY DESIGN We searched PubMed, the Cochrane Library, and the EMBASE database, limiting the search to human patients and articles in English published until December 31, 2021. The effect size and 95% confidence interval (CI) were defined as the odds ratio (OR) and 95% CI, respectively, to indicate the difference in the incidence of delirium between statin use and nonuse groups. A random-effects model was selected in the case of high heterogeneity of study populations. We used funnel plots, Egger test, Duval and Tweedie trim-and-fill approach, and the classic fail-safe N to assess publication bias. RESULTS Of a total of 264 identified studies, 13 were selected for the qualitative review-4 RCTs and 9 observational cohort studies. Statin use was not associated with low delirium risk (pooled OR, 0·82; 95% CI, 0·64-1·04; P = 0·09). Substantial statistical heterogeneity was observed (I2, 90%). Visual inspection of the funnel plot of ORs from the studies revealed symmetry. Using the Grading of Recommendations Assessment, Development, and Evaluation approach, we assigned the evidence a rating of C and a weak recommendation for this review. CONCLUSIONS Statin use is not associated with delirium risk. More comprehensive RCTs are required to confirm the results.
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Bondy SC. Melatonin and Aging. Subcell Biochem 2023; 103:291-307. [PMID: 37120473 DOI: 10.1007/978-3-031-26576-1_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
The health problems associated with the aging process are becoming increasingly widespread due to the increase in mean life expectancy taking place globally. While decline of many organ functions is an unavoidable concomitant of senescence, these can be delayed or moderated by a range of factors. Among these are dietary changes and weight control, taking sufficient exercise, and the utilization of various micronutrients. The utility of incurring appropriate changes in lifestyle is generally not confined to a single organ system but has a broadly positive systemic effect.Among one of the most potent means of slowing down age-related changes is the use of melatonin, a widely distributed biological indole. While melatonin is well known as a treatment for insomnia, it has a wide range of beneficial qualities many of which are relevant. This overview describes how several of the properties of melatonin are especially relevant to many of the changes associated with senescence. Changes in functioning of the immune system are particularly marked in the aged, combining diminishing effectiveness with increasing ineffective and harmful activity. Melatonin treatment appears able to moderate and partially reverse this detrimental drift toward immune incompetence.
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Affiliation(s)
- Stephen C Bondy
- Center for Occupational and Environmental Health, University of California, Irvine, CA, USA.
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Hatta K, Usui C, Nakamura H. Acceptability of transdermal antipsychotic patches by patients who refuse oral medication and their effectiveness in preventing recurrence of delirium: a retrospective observational study. Int Clin Psychopharmacol 2023; 38:23-27. [PMID: 35980004 PMCID: PMC9722369 DOI: 10.1097/yic.0000000000000428] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Injectable antipsychotics had been used for patients who refuse oral medications in delirium practice. The objectives were to investigate acceptability of transdermal antipsychotic patches by patients who refuse oral medications and their effectiveness in preventing recurrence of delirium. In this retrospective observational study, data were collected between October 2019 and December 2021. The sample was represented by patients hospitalized because of acute diseases or elective surgery who had delirium on the night before the consultation and had refused oral therapy after consultation. Delirium has been diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Instead, a transdermal patch of blonanserin, a second-generation antipsychotic drug, was tried. The primary outcome was the rate of patients who accepted it. The secondary outcome was recurrence rates of delirium. As much as 95.1% of patients who refused oral medications (98/103 patients) accepted to receive the transdermal patch. Of these, 24 patients developed delirium again, whereas all five patients who refused it developed delirium again [24.5% (24/98) vs. 100% (5/5); P = 0.0014]. The present findings suggest that transdermal antipsychotic patches are more likely to be accepted by patients who refuse oral medications. Prospective studies are needed.
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Affiliation(s)
- Kotaro Hatta
- Department of Psychiatry, Juntendo University Nerima Hospital, Tokyo
| | - Chie Usui
- Department of Psychiatry, Juntendo University Nerima Hospital, Tokyo
| | - Hiroyuki Nakamura
- Department of Environmental and Preventive Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
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Melatonin for Insomnia in Medical Inpatients: A Narrative Review. J Clin Med 2022; 12:jcm12010256. [PMID: 36615056 PMCID: PMC9821578 DOI: 10.3390/jcm12010256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/07/2022] [Accepted: 12/15/2022] [Indexed: 12/31/2022] Open
Abstract
In this narrative review, we describe what is known about non-pharmacological and pharmacological treatments for insomnia in medical inpatients, with a focus on melatonin. Hospital-acquired insomnia is common, resulting in shortened total sleep time and more nighttime awakenings. Sleep disturbance has been shown to increase systemic inflammation, pain, and the likelihood of developing delirium in hospital. Treatment for insomnia includes both non-pharmacological and pharmacological interventions, the latter of which requires careful consideration of risks and benefits given the known adverse effects. Though benzodiazepines and non-benzodiazepine benzodiazepine receptor agonists are commonly prescribed (i.e., sedative-hypnotics), they are relatively contraindicated for patients over the age of 65 due to the risk of increased falls, cognitive decline, and potential for withdrawal symptoms after long-term use. Exogenous melatonin has a comparatively low likelihood of adverse effects and drug-drug interactions and is at least as effective as other sedative-hypnotics. Though more research is needed on both its effectiveness and relative safety for inpatients, small doses of melatonin before bedtime may be an appropriate choice for inpatients when insomnia persists despite non-pharmacological interventions.
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Trzepacz PT, Franco JG, Meagher D, Kishi Y, Sepúlveda E, Gaviria AM, Chen CH, Huang MC, Furlanetto LM, Negreiros D, Lee Y, Kim JL, Kean J. Delusions and Hallucinations Are Associated With Greater Severity of Delirium. J Acad Consult Liaison Psychiatry 2022; 64:236-247. [PMID: 36539078 DOI: 10.1016/j.jaclp.2022.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/10/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The 3 core domains of delirium (cognitive, higher level thinking, circadian) do not include the less common noncore psychotic symptoms. However, psychosis might inform about perturbations of neural circuitry, outcomes, or suggest tailored clinical management. OBJECTIVE We assessed for the first time the relationships between psychosis and other characteristics of delirium in patients without confounders for delirium phenotype, such as dementia or antipsychotics treatment. METHODS Cross-sectional analysis of 366 adults with delirium per the Delirium Rating Scale Revised-98, whose items distinguish hallucinations and delusions from other types of misperceptions and abnormal thought content, assessed during the preceding 24 hours to capture symptom severity fluctuation. The relationship of psychosis with other delirium characteristics was assessed using bivariate comparisons and analysis of variance as appropriate for groups with no psychosis and any psychosis (hallucinations and/or delusions), and subgroups with only hallucinations, only delusions, or both. A discriminant logistic model assessed variables associated with presence of any psychotic features versus none. RESULTS Delirium with any psychotic features occurred in 44.5% (163 of 366). Of the 366, 119 (32.5%) had only hallucinations (Hall), 14 (3.8%) had only delusions (Del), and 30 (8.2%) had both (Both). In the psychotic group (n = 163), 73.0% were Hall, 8.6% Del, and 18.4% Both. All psychotic patient groupings had significantly greater delirium severity on the Delirium Rating Scale Revised-98. Delusions and hallucinations were discordant for occurring together. The discriminant model found increased odds of having psychosis as 3 symptom severities increased (visuospatial ability, thought process, and sleep-wake cycle) where these each represented a delirium core domain. The noncore symptom of lability of affect had high odds ratio for psychosis, while motor retardation reduced odds of psychosis in this model. CONCLUSIONS Consistent with prior reports, psychosis occurred in less than half of delirious patients with delusions being infrequent, and an association with affective lability was found. We are the first to report that psychotic features are a marker for more severe delirium affecting all core domains. Given that previous functional magnetic resonance imaging research found a correlation between neural network dysconnectivity with greater severity of delirium, psychotic symptoms might be a clinical marker for greater underlying cerebral cortical neural circuitry dysfunction.
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Affiliation(s)
- Paula T Trzepacz
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
| | - José G Franco
- Grupo de Investigación en Psiquiatría de Enlace (GIPE), Facultad de Medicina, Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - David Meagher
- Cognitive Impairment Research Group (CIRG), Graduate-Entry Medical School, University of Limerick, Limerick, Ireland
| | - Yasuhiro Kishi
- Department of Psychiatry, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Esteban Sepúlveda
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Hospital Psiquiàtric Universitari Institut Pere Mata, IISPV, Reus, Spain; Universitat Rovira i Virgili, Tarragona, Spain
| | - Ana M Gaviria
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Hospital Psiquiàtric Universitari Institut Pere Mata, IISPV, Reus, Spain; Facultad de Ciencias de la Salud, Fundación Universitaria María Cano, Medellín, Colombia
| | - Chun-Hsin Chen
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Psychiatry, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ming-Chyi Huang
- Department of Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan
| | - Leticia M Furlanetto
- Department of Internal Medicine, Federal University of Santa Catarina, Florianopolis, Brazil
| | - Daniel Negreiros
- Department of Internal Medicine, Federal University of Santa Catarina, Florianopolis, Brazil
| | - Yanghyun Lee
- Chilgok Yeonhap Mental Health Clinic, Daegu, South Korea
| | - Jeong-Lan Kim
- Department of Psychiatry, College of Medicine, Chungnam National University, Daejeon, South Korea
| | - Jacob Kean
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT
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Maneeton B, Kongsaengdao S, Maneeton N, Likhitsathian S, Woottiluk P, Kawilapat S, Srisurapanont M. Melatonin Receptor Agonists for the Prevention of Delirium: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials. Curr Neuropharmacol 2022; 20:1956-1968. [PMID: 35524672 PMCID: PMC9886800 DOI: 10.2174/1570159x20666220507024219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 02/10/2022] [Accepted: 04/19/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although a previous review illustrated the efficacy of melatonin receptor agonists (MRAs) in preventing delirium, some recent randomized controlled trials (RCTs) did not confirm these effects. OBJECTIVES This study systematically reviewed the efficacy, acceptability, and tolerability of MRAs for delirium prevention. MATERIALS AND METHODS We searched electronic databases, including Scopus, PubMed, CINAHL, and Controlled Trials Register, from their inception to February 20, 2022. The primary efficacy outcome was delirium incidence rate after MRA administration; relative risks (RRs), overall discontinuation, and discontinuation due to adverse events are also presented. RESULTS The overall pooled incidence rates of delirium in MRA-treated and placebo-treated groups were significantly different with RR (95% CI)=0.66(0.52, 0.84, ), I2=59%. Similarly, the incidence rate was significantly lower in the melatonin-treated group than in the placebo-treated group [RR (95% CI) =0.65 (0.49, 0.88), I2=65%]. Unfortunately, incidence rates were not significantly different between ramelteon-treated and placebo-treated groups [RR (95% CI) =0.67 (0.42, 1.08), I2=50%]. The pooled incidence rate of delirium in either melatonin or ramelteon-treated groups was not significantly different from the placebo-treated group in elderly patients. The pooled incidence rate of delirium was significantly lower in the melatonin-treated group than in the benzodiazepinetreated group. CONCLUSION Based on this review, melatonin could prevent delirium with a small effect size. However, ramelteon did not show efficacy in preventing delirium. Additionally, neither melatonin nor ramelteon individually showed effectiveness in preventing delirium in elderly patients. Therefore, using MRAs to prevent delirium in clinical practice should be cautious. However, future welldefined and large sample size studies could verify these findings.
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Affiliation(s)
| | | | - Narong Maneeton
- Address correspondence to this author at the Department of Psychiatry, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Sriphum, Amphur Muang, Chiang Mai 50200, Thailand; Tel: +66 53 93 5422; Fax: +66 53 5426; E-mail:
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Schmidt S, Hancke L, Haussmann R, Luetz A. [Chronobiological interventions for prevention and treatment of delirium in critically ill patients]. DER NERVENARZT 2022; 93:901-911. [PMID: 35867117 DOI: 10.1007/s00115-022-01348-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 10/17/2022]
Abstract
Circadian body and behavior rhythms serve to coordinate and maintain the physiological processes in the human body. A disruption of these rhythms frequently occurs in intensive care patients and can be the cause for the development of delirium. This review article discusses the underlying pathophysiological mechanisms and develops a chronobiologically oriented prevention and treatment approach for delirium in the context of intensive care medicine.
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Affiliation(s)
- Sebastian Schmidt
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Laura Hancke
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Robert Haussmann
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl Gustav Carus Dresden, Dresden, Deutschland
| | - Alawi Luetz
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum and Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland. .,Fachgebiet Management im Gesundheitswesen, Technische Universität Berlin, Berlin, Deutschland.
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Lee S, Chen H, Hibino S, Miller D, Healy H, Lee JS, Arendts G, Han JH, Kennedy M, Carpenter CR. Can we improve delirium prevention and treatment in the emergency department? A systematic review. J Am Geriatr Soc 2022; 70:1838-1849. [PMID: 35274738 PMCID: PMC9314609 DOI: 10.1111/jgs.17740] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/31/2022] [Accepted: 02/17/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND This systematic review was conducted to evaluate any interventions to prevent incident delirium, or shorten the duration of prevalent delirium, in older adults presenting to the emergency department (ED). METHODS Health sciences librarian designed electronic searches were conducted from database inception through September 2021. Two authors reviewed studies, and included studies that evaluated interventions for the prevention and/or treatment of delirium and excluded non-ED studies. The risk of bias (ROB) was evaluated by the Cochrane ROB tool or the Newcastle-Ottawa (NOS) scale. Meta-analysis was conducted to estimate a pooled effect of multifactorial programs on delirium prevention. RESULTS Our search strategy yielded 11,900 studies of which 10 met study inclusion criteria. Two RCTs evaluated pharmacologic interventions for delirium prevention; three non-RCTs employed a multi-factorial delirium prevention program; three non-RCTs evaluated regional anesthesia for hip fractures; and one study evaluated the use of Foley catheter, medication exposure, and risk of delirium. Only four studies demonstrated a significant impact on delirium incidence or duration of delirium-one RCT of melatonin reduced the incidence of delirium (OR 0.19, 95% CI 0.06 to 0.62), one non-RCT study on a multi-factorial program decreased inpatient delirium prevalence (41% to 19%) and the other reduced incident delirium (RR 0.37, 95% CI 0.22 to 0.61). One case-control study on the use of ED Foley catheters in the ED increased the duration of delirium (proportional OR 3.1, 95% CI 1.3 to 7.4). A pooled odds ratio for three multifactorial programs on delirium prevention was 0.46 (95% CI 0.31-0.68, I2 = 0). CONCLUSION Few interventions initiated in the ED were found to consistently reduce the incidence or duration of delirium. Delirium prevention and treatment trials in the ED are still rare and should be prioritized for future research.
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Affiliation(s)
- Sangil Lee
- Department of Emergency MedicineUniversity of Iowa Roy J and Lucille A Carver College of MedicineIowa CityIowaUSA
| | - Hao Chen
- Department of Emergency MedicineUniversity of Iowa Roy J and Lucille A Carver College of MedicineIowa CityIowaUSA
| | - Seikei Hibino
- Department of Emergency MedicineUniversity of Minnesota Medical CenterMinneapolisMinnesotaUSA
| | - Daniel Miller
- Department of Emergency MedicineUniversity of Iowa Roy J and Lucille A Carver College of MedicineIowa CityIowaUSA
| | - Heather Healy
- Hardin Library for the Health SciencesUniversity of IowaIowa CityIowaUSA
| | - Jacques S. Lee
- Schwartz/Reisman Emergency Medicine InstituteSinai HealthTorontoONCanada
- Department of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Glenn Arendts
- Emergency MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia
| | - Jin Ho Han
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Geriatric Research, Education, and Clinical CenterTennessee Valley Healthcare SystemNashvilleTennesseeUSA
| | - Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
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Therapeutic Approach to Alzheimer’s Disease: Current Treatments and New Perspectives. Pharmaceutics 2022; 14:pharmaceutics14061117. [PMID: 35745693 PMCID: PMC9228613 DOI: 10.3390/pharmaceutics14061117] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 12/11/2022] Open
Abstract
Alzheimer’s disease (AD) is the most common cause of dementia. The pathophysiology of this disease is characterized by the accumulation of amyloid-β, leading to the formation of senile plaques, and by the intracellular presence of neurofibrillary tangles based on hyperphosphorylated tau protein. In the therapeutic approach to AD, we can identify three important fronts: the approved drugs currently available for the treatment of the disease, which include aducanumab, donepezil, galantamine, rivastigmine, memantine, and a combination of memantine and donepezil; therapies under investigation that work mainly on Aβ pathology and tau pathology, and which include γ-secretase inhibitors, β-secretase inhibitors, α-secretase modulators, aggregation inhibitors, metal interfering drugs, drugs that enhance Aβ clearance, inhibitors of tau protein hyperphosphorylation, tau protein aggregation inhibitors, and drugs that promote the clearance of tau, and finally, other alternative therapies designed to improve lifestyle, thus contributing to the prevention of the disease. Therefore, the aim of this review was to analyze and describe current treatments and possible future alternatives in the therapeutic approach to AD.
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You W, Fan XY, Lei C, Nie CC, Chen Y, Wang XL. Melatonin intervention to prevent delirium in hospitalized patients: A meta-analysis. World J Clin Cases 2022; 10:3773-3786. [PMID: 35647160 PMCID: PMC9100708 DOI: 10.12998/wjcc.v10.i12.3773] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/01/2021] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Evaluation of the effectiveness of melatonin is necessary to prevent the development of delirium in hospitalized patients. Melatonin (N-acetyl-5-methoxytryptamine) is a hormone produced by the pineal gland of the brain from the amino acid tryptophan. Synthetic melatonin supplements have been used for various medical conditions, especially sleep-related diseases, and have proved to be successful.
AIM To determine the effect of melatonin on the prevention of delirium in hospitalized patients.
METHODS A literature search of the CNKI, Wanfang Database, VIP Database, China Biomedical Literature Database, PubMed, Embase, Cochrane Library, Web of Science, and other databases was conducted. The CNKI, Wanfang Database, VIP Database (VIP), and China Biomedical Literature Database were searched for Chinese studies, and PubMed, Embase, Cochrane Library, Web of Science and other databases were searched for international studies. It will be established in June 2021 in a randomized controlled trial (RCT) whether melatonin treatment for 6 mo prevents delirium in hospitalized patients. Literature screening, quality review, and data extraction were carried out using the Cochrane Manual 5.1.0 systematic evaluation method, and Stata 15.0 software and Review Manager 5.3 were used for meta-analysis and processing.
RESULTS A total of 18 new RCT articles and 18 experimental subjects were identified. The results of the meta-analysis showed that following the occurrence of delirium, melatonin reduced the incidence of delirium in patients (RR = 0.69, 95%CI: 0.60-0.80), which is of significance, but heterogeneity was significant I2 = 62%. Subgroup analysis was performed to examine the source of heterogeneity, and it was found that different patient types were the source of heterogeneity; the research on subgroup analysis was of high quality and homogeneous. To determine the reliability and robustness of the research results, a sensitivity analysis was carried out. The results showed that after excluding individual studies one by one, the effect size was still within 95%CI, which strengthened the reliability of the original meta-analysis results. Melatonin has a significant preventive effect on delirium in hospitalized medical patients [RR = 0.60, 95%CI: 0.47-0.76), P < 0.001].
CONCLUSION Melatonin can reduce the rate of delirium in medical patients, and the role of melatonin in reducing the incidence of delirium in surgical patients and critical care unit patients requires further study.
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Affiliation(s)
- Wei You
- Emergency Department Intensive Care Unit, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Xiao-Yu Fan
- Department of General Surgery, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Cheng Lei
- School of Public Health and Management, Chongqing Medical University, Chongqing 400000, Chongqing, China
| | - Chen-Cong Nie
- Department of Nursing, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Yao Chen
- Emergency Department Intensive Care Unit, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
| | - Xue-Lian Wang
- Emergency Department Intensive Care Unit, Zigong Fourth People's Hospital, Zigong 643000, Sichuan Province, China
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Ohsako N, Hashimoto T, Shiko Y, Kawasaki Y, Nakagawa M, Okuma T, Kurata T, Suzuki H, Ishige M, Kikuchi S. Pharmacotherapy for elderly patients with delirium in a general ward setting: A retrospective study. Asian J Psychiatr 2022; 70:103024. [PMID: 35219983 DOI: 10.1016/j.ajp.2022.103024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/17/2022] [Accepted: 02/11/2022] [Indexed: 11/26/2022]
Abstract
Antipsychotic medications are widely used in patients with delirium. However, antipsychotics may lead to various adverse events including cardiac arrythmias, extrapyramidal side effects, and oversedation. This study aimed to investigate whether non-antipsychotic medications including ramelteon, suvorexant, and trazodone are useful for the treatment of elderly inpatients with delirium in a general ward setting. This was a retrospective cohort study using medical chart reviews of all consecutive inpatients with hyperactive forms of delirium who were admitted to a regional general hospital. The primary outcome of this study was to evaluate whether non-antipsychotic medication (ramelteon, suvorexant, and trazodone) is inferior, in terms of efficacy and safety, to antipsychotic medication in delirium treatment. Of 154 patients who consulted psychiatrists during the study period, 33 patients were diagnosed with hyperactive delirium. Of these patients, 21 were categorized into the antipsychotic medication group, and 12 were categorized into the non-antipsychotic medication group. The duration of delirium after pharmacological treatments was not statistically different between the two groups. However, the rates of adverse events related to psychotropic medications in the antipsychotic medication group were significantly higher than that in the non-antipsychotic medication group. This study demonstrated that, in the treatment of elderly patients with delirium, non-antipsychotic drugs, such as suvorexant, ramelteon, and trazodone, could be more useful than antipsychotics in terms of efficacy and safety.
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Affiliation(s)
- Noriaki Ohsako
- Department of Psychiatry, Sodegaura Satsukidai Hospital, Sodegaura, Japan; Department of Psychiatry, School of Medicine, International University of Health and Welfare, Narita, Japan; Department of Psychiatry, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tasuku Hashimoto
- Department of Psychiatry, Sodegaura Satsukidai Hospital, Sodegaura, Japan; Department of Psychiatry, School of Medicine, International University of Health and Welfare, Narita, Japan; Department of Psychiatry, Graduate School of Medicine, Chiba University, Chiba, Japan.
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan; Faculty of Nursing, Japanese Red Cross College of Nursing, Tokyo, Japan
| | - Mei Nakagawa
- Department of Psychiatry, Sodegaura Satsukidai Hospital, Sodegaura, Japan
| | - Takahiro Okuma
- Department of Psychiatry, Sodegaura Satsukidai Hospital, Sodegaura, Japan
| | - Tsutomu Kurata
- Department of Psychiatry, Sodegaura Satsukidai Hospital, Sodegaura, Japan
| | - Hitoshi Suzuki
- Department of Psychiatry, Sodegaura Satsukidai Hospital, Sodegaura, Japan
| | - Minoru Ishige
- Department of Psychiatry, Sodegaura Satsukidai Hospital, Sodegaura, Japan
| | - Shuichi Kikuchi
- Department of Psychiatry, Sodegaura Satsukidai Hospital, Sodegaura, Japan
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Melatonin in ICU delirium: shining light on the hormone of darkness. Intensive Care Med 2022; 48:479-481. [PMID: 35257204 DOI: 10.1007/s00134-022-06656-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Wibrow B, Martinez FE, Myers E, Chapman A, Litton E, Ho KM, Regli A, Hawkins D, Ford A, van Haren FMP, Wyer S, McCaffrey J, Rashid A, Kelty E, Murray K, Anstey M. Prophylactic melatonin for delirium in intensive care (Pro-MEDIC): a randomized controlled trial. Intensive Care Med 2022; 48:414-425. [DOI: 10.1007/s00134-022-06638-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/28/2022] [Indexed: 12/16/2022]
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HATTA KOTARO. Prevention of Delirium Via Melatonin and Orexin Neurotransmission. JUNTENDO IJI ZASSHI = JUNTENDO MEDICAL JOURNAL 2022; 68:12-16. [PMID: 38911008 PMCID: PMC11189796 DOI: 10.14789/jmj.jmj21-0035-r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/10/2021] [Indexed: 06/25/2024]
Abstract
The fundamental conception of delirium is altered arousal. In addition, sleep-wake cycle isturbances including insomnia, excessive daytime napping, and disintegration of the xpected circadian patterns have been described as a characteristic component of delirium or decades, and demonstrated to be a core symptom domain of delirium. Although on-pharmacological interventions are successful to some extent, they have limitations due o various biological etiologies for delirium. Among pharmacological interventions, ntipsychotics seem to be effective, but they are not suitable for preventive use because f relatively frequent side-effects such as extrapyramidal symptoms. Recently, new type of rugs for insomnia have been focused with respect to delirium prevention. Recent eta-analyses show effectiveness of melatonin receptor agonists and orexin receptor ntagonists for delirium prevention, and real-world data support them.
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Affiliation(s)
- KOTARO HATTA
- Corresponding author: Kotaro Hatta, Department of Psychiatry, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima-ku, Tokyo 177-8521, Japan, TEL: +81-3-5923-3111 E-mail:
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47
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Lam MTY, Malhotra A, LaBuzetta JN, Kamdar BB. Sleep in Critical Illness. Respir Med 2022. [DOI: 10.1007/978-3-030-93739-3_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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48
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O’Gara BP, Gao L, Marcantonio ER, Subramaniam B. Sleep, Pain, and Cognition: Modifiable Targets for Optimal Perioperative Brain Health. Anesthesiology 2021; 135:1132-1152. [PMID: 34731233 PMCID: PMC8578455 DOI: 10.1097/aln.0000000000004046] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The prevention of perioperative neurocognitive disorders is a priority for patients, families, clinicians, and researchers. Given the multiple risk factors present throughout the perioperative period, a multicomponent preventative approach may be most effective. The objectives of this narrative review are to highlight the importance of sleep, pain, and cognition on the risk of perioperative neurocognitive disorders and to discuss the evidence behind interventions targeting these modifiable risk factors. Sleep disruption is associated with postoperative delirium, but the benefit of sleep-related interventions is uncertain. Pain is a risk factor for postoperative delirium, but its impact on other postoperative neurocognitive disorders is unknown. Multimodal analgesia and opioid avoidance are emerging as best practices, but data supporting their efficacy to prevent delirium are limited. Poor preoperative cognitive function is a strong predictor of postoperative neurocognitive disorder, and work is ongoing to determine whether it can be modified to prevent perioperative neurocognitive disorders.
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Affiliation(s)
- Brian P O’Gara
- Beth Israel Deaconess Medical Center. Department of Anesthesiology, Critical Care and Pain Medicine. Harvard Medical School. Boston, MA, USA
| | - Lei Gao
- Massachusetts General Hospital. Department of Anesthesia. Harvard Medical School. Boston, MA, USA
| | - Edward R Marcantonio
- Beth Israel Deaconess Medical Center. Department of Medicine. Harvard Medical School. Boston, MA, USA
| | - Balachundhar Subramaniam
- Beth Israel Deaconess Medical Center. Department of Anesthesiology, Critical Care and Pain Medicine. Harvard Medical School. Boston, MA, USA
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49
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LaHue SC, Douglas VC. Approach to Altered Mental Status and Inpatient Delirium. Neurol Clin 2021; 40:45-57. [PMID: 34798974 DOI: 10.1016/j.ncl.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Altered mental status is a nonspecific diagnosis that encompasses a wide spectrum of disease and is frequently cited as a reason for both hospital admission and inpatient neurologic consultation. There are numerous etiologies of altered mental status, and so although many are facile with the workup of this potentially life-threatening entity, it can nevertheless be overwhelming. Our goal was to provide a practical framework embedded in a current, comprehensive review of the epidemiology, clinical evaluation, and management of undifferentiated altered mental status. We pay particular attention to the management of a critical yet underdiagnosed subtype of altered mental status: delirium.
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Affiliation(s)
- Sara C LaHue
- Department of Neurology, School of Medicine, University of California, San Francisco, CA, USA; Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA.
| | - Vanja C Douglas
- Department of Neurology, School of Medicine, University of California, San Francisco, CA, USA; Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
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50
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Huang DD, Fischer PE. Management of Delirium in the Intensive Care Unit. Surg Clin North Am 2021; 102:139-148. [PMID: 34800382 DOI: 10.1016/j.suc.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In the intensive care unit, delirium is a major contributor to morbidity and mortality in adult patients. Patients with delirium have been shown to have increased length of stay, decreased functional outcomes, and increased risk for requiring placement at the time of discharge. In addition, decreased cognitive function and dementia have been shown to be long-term complications from delirium. The mainstay of treatment and prevention include therapy- and behavioral-based interventions, including frequent orientation, cognitive stimulation, mobilization, sleep restoration, and providing hearing and visual aids. Refractory delirium may require pharmacologic intervention with antipsychotics or alpha-2 agonists.
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Affiliation(s)
- Dih-Dih Huang
- University of Tennessee Health Science Center, 910 Madison Avenue, Suite 220, Memphis, TN 38163, USA.
| | - Peter E Fischer
- University of Tennessee Health Science Center, 910 Madison Avenue, Suite 220, Memphis, TN 38163, USA
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