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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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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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Ehrlich A, Oh ES, Ahmed S. Managing Delirium in the Emergency Department: An Updated Narrative Review. CURRENT GERIATRICS REPORTS 2024; 13:52-60. [PMID: 38855352 PMCID: PMC11156174 DOI: 10.1007/s13670-024-00413-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2024] [Indexed: 06/11/2024]
Abstract
Purpose of Review Emergency departments (EDs) are facing an epidemic of overcrowding and ED boarding, particularly of older adults who often present with, or develop, delirium in the ED. Delirium is associated with increased complications, longer hospital length of stay, mortality, and costs to the healthcare system. However, we only have limited knowledge of how to successfully prevent and treat delirium in the ED in a pragmatic, sustainable, and cost-effective way. We present a narrative review of recent literature of delirium prevention and treatment programs in the ED. We aim to describe the components of successful delirium management strategies to be used by EDs in building delirium management programs. Recent Findings We reviewed 10 studies (2005-2023) that report delirium interventions in the ED, and describe the different components of these interventions that have been studied. These interventions included: optimizing hemodynamics and oxygenation, treating pain, hydration and nutrition support, avoiding sedative hypnotics, antipsychotics and anticholinergics, promoting sleep, sensory stimulation, limiting the time spent in the ED, educating providers and staff, and developing multidisciplinary delirium protocols integrated into the electronic health record. Summary Through our narrative review of the recent literature on delirium prevention and treatment programs in the ED, we have identified nine components of successful delirium prevention strategies in the ED. We also discuss three high priority areas for further research including identification of most effective components of delirium prevention strategies, conduct of additional high-quality trials in non-hip.
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Affiliation(s)
- April Ehrlich
- Division of Geriatric Medicine and Gerontology, Department of Medicine, The Johns Hopkins University, 5200, Eastern Avenue, Suite , 2200 Baltimore, MD, 21224, USA
| | - Esther S. Oh
- Division of Geriatric Medicine and Gerontology, Department of Medicine, The Johns Hopkins University, 5200, Eastern Avenue, Suite , 2200 Baltimore, MD, 21224, USA
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University, Baltimore, MD, USA
- Division of Neuropathology, Department of Pathology, The Johns Hopkins University, Baltimore, MD, USA
- The Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - Shaista Ahmed
- Division of Geriatric Medicine and Gerontology, Department of Medicine, The Johns Hopkins University, 5200, Eastern Avenue, Suite , 2200 Baltimore, MD, 21224, USA
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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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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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Bonfichi A, Ceresa IF, Piccioni A, Zanza C, Longhitano Y, Boudi Z, Esposito C, Savioli G. A Lethal Combination of Delirium and Overcrowding in the Emergency Department. J Clin Med 2023; 12:6587. [PMID: 37892725 PMCID: PMC10607343 DOI: 10.3390/jcm12206587] [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: 08/28/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Delirium is a common public health concern that significantly impacts older patients admitted to the Emergency Department (ED). This condition is linked to adverse outcomes such as reduced long-term functionality, higher mortality rates, extended hospital stays, and increased medical costs. The identification of risk factors is crucial for the early recognition and management of delirium in ED patients. Aging, cognitive decline, polypharmacy, and sensory impairment are some of the most common general risk factors described in the literature. Although validated delirium assessment tools already exist, they are not practical for the fast-paced ED environment because of their extended evaluation period or specialized training request. Moreover, clear guidance is needed to select the most suitable tool for detecting delirium, balancing between the accuracy and the swiftness required in an overcrowded, high-stress, and understaffed healthcare setting. This narrative review aims to analyze the updated literature on delirium risk factors in older ED patients and focuses on the methods for better screening, managing, and treating this condition in the ED.
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Affiliation(s)
- Alessandra Bonfichi
- Department of Internal Medicine, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
| | - Iride Francesca Ceresa
- Department of Emergency Medicine, Humanitas University-Research Hospital, 20089 Rozzano, Italy; (I.F.C.); (Y.L.)
| | - Andrea Piccioni
- Department of Emergency, Fondazione Policlinico Universitario A. Gemelli, IRCCS Fondazione Policlinico San Matteo, 00168 Roma, Italy;
| | - Christian Zanza
- Italian Society of Pre-Hospital Emergency Medicine (SIS-118), 74121 Taranto, Italy;
| | - Yaroslava Longhitano
- Department of Emergency Medicine, Humanitas University-Research Hospital, 20089 Rozzano, Italy; (I.F.C.); (Y.L.)
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15260, USA
| | - Zoubir Boudi
- Department of Emergency Medicine, Dr Sulaiman Alhabib Hospital, Dubai 2542, United Arab Emirates;
| | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy;
| | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
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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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Cao Y, Song Y, Ding Y, Ni J, Zhu B, Shen J, Miao L. The role of hormones in the pathogenesis and treatment mechanisms of delirium in ICU: The past, the present, and the future. J Steroid Biochem Mol Biol 2023; 233:106356. [PMID: 37385414 DOI: 10.1016/j.jsbmb.2023.106356] [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: 06/05/2023] [Revised: 06/18/2023] [Accepted: 06/26/2023] [Indexed: 07/01/2023]
Abstract
Delirium is an acute brain dysfunction. As one of the common psychiatric disorders in ICU, it can seriously affect the prognosis of patients. Hormones are important messenger substances found in the human body that help to regulate and maintain the function and metabolism of various tissues and organs. They are also one of the most commonly used drugs in clinical practice. Recent evidences suggest that aberrant swings in cortisol and non-cortisol hormones might induce severe cognitive impairment, eventually leading to delirium. However, the role of hormones in the pathogenesis of delirium still remains controversial. This article reviews the recent research on risk factors of delirium and the association between several types of hormones and cognitive dysfunction. These mechanisms are expected to offer novel ideas and clinical relevance for the treatment and prevention of delirium.
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Affiliation(s)
- Yuchun Cao
- Department of Critical Care Medicine, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China
| | - Yuwei Song
- Department of Critical Care Medicine, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China
| | - Yuan Ding
- Department of Critical Care Medicine, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China
| | - Jiayuan Ni
- Department of Critical Care Medicine, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China
| | - Bin Zhu
- Department of Critical Care Medicine, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China
| | - Jianqin Shen
- Department of Blood Purification Center, the Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China.
| | - Liying Miao
- Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou 213000, Jiangsu, China.
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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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Ryan SL, Liu X, McKenna V, Ghanta M, Muniz C, Renwick R, Westover MB, Kimchi EY. Associations between early in-hospital medications and the development of delirium in patients with stroke. J Stroke Cerebrovasc Dis 2023; 32:107249. [PMID: 37536017 PMCID: PMC10529367 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 06/29/2023] [Accepted: 07/06/2023] [Indexed: 08/05/2023] Open
Abstract
OBJECTIVES Patients hospitalized with stroke develop delirium at higher rates than general hospitalized patients. While several medications are associated with existing delirium, it is unknown whether early medication exposures are associated with subsequent delirium in patients with stroke. Additionally, it is unknown whether delirium identification is associated with changes in the prescription of these medications. MATERIALS AND METHODS We conducted a retrospective cohort study of patients admitted to a comprehensive stroke center, who were assessed for delirium by trained nursing staff during clinical care. We analyzed exposures to multiple medication classes in the first 48 h of admission, and compared them between patients who developed delirium >48 hours after admission and those who never developed delirium. Statistical analysis was performed using univariate testing. Multivariable logistic regression was used further to evaluate the significance of univariately significant medications, while controlling for clinical confounders. RESULTS 1671 unique patients were included in the cohort, of whom 464 (27.8%) developed delirium >48 hours after admission. Delirium was associated with prior exposure to antipsychotics, sedatives, opiates, and antimicrobials. Antipsychotics, sedatives, and antimicrobials remained significantly associated with delirium even after accounting for several clinical covariates. Usage of these medications decreased in the 48 hours following delirium identification, except for atypical antipsychotics, whose use increased. Other medication classes such as steroids, benzodiazepines, and sleep aids were not initially associated with subsequent delirium, but prescription patterns still changed after delirium identification. CONCLUSIONS Early exposure to multiple medication classes is associated with the subsequent development of delirium in patients with stroke. Additionally, prescription patterns changed following delirium identification, suggesting that some of the associated medication classes may represent modifiable targets for future delirium prevention strategies, although future study is needed.
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Affiliation(s)
- Sophia L Ryan
- Department of Neurology, Massachusetts General Hospital, USA; Department of Neurology, Mount Sinai Medical Center, India
| | - Xiu Liu
- Department of Neurology, Massachusetts General Hospital, USA; Lawrence Center for Quality and Safety, Massachusetts General Hospital, USA
| | - Vanessa McKenna
- Department of Neurology, Massachusetts General Hospital, USA
| | - Manohar Ghanta
- Department of Neurology, Massachusetts General Hospital, USA
| | - Carlos Muniz
- Department of Neurology, Massachusetts General Hospital, USA; Department of Neurology, SUNY Upstate Medical University, USA
| | - Rachel Renwick
- Department of Neurology, Massachusetts General Hospital, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, USA; Department of Neurology, Beth Israel Deaconess Medical Center, USA
| | - Eyal Y Kimchi
- Department of Neurology, Massachusetts General Hospital, USA; Department of Neurology, Northwestern University, USA.
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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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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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[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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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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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: 18] [Impact Index Per Article: 9.0] [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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Nasseh N, Khezri MB, Farzam S, Shiravandi S, Shafikhani AA. The effect of melatonin on cardiac biomarkers after coronary artery bypass graft surgery: A double-blind, randomized pilot study. J Cardiothorac Vasc Anesth 2022; 36:3800-3805. [DOI: 10.1053/j.jvca.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 05/17/2022] [Accepted: 06/05/2022] [Indexed: 11/11/2022]
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Ohki S, Kunimatsu M, Ogawa S, Takano H, Furihata T, Shibasaki H, Yokokawa A. Development and Validation of an LC–MS/MS-Based Method for Quantifying Urinary Endogenous 6-Hydroxymelatonin. Chem Pharm Bull (Tokyo) 2022; 70:375-382. [DOI: 10.1248/cpb.c21-00982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Seiya Ohki
- Laboratory of Clinical Pharmacy and Experimental Therapeutics, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences
| | - Miyu Kunimatsu
- Laboratory of Clinical Pharmacy and Experimental Therapeutics, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences
| | - Shingo Ogawa
- Laboratory of Clinical Pharmacy and Experimental Therapeutics, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences
| | - Hiroki Takano
- Laboratory of Clinical Pharmacy and Experimental Therapeutics, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences
| | - Tomomi Furihata
- Laboratory of Clinical Pharmacy and Experimental Therapeutics, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences
| | - Hiromi Shibasaki
- Laboratory of Clinical Pharmacy and Experimental Therapeutics, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences
| | - Akitomo Yokokawa
- Laboratory of Clinical Pharmacy and Experimental Therapeutics, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences
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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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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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22
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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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Sigaut S, Couffignal C, Esposito-Farèse M, Degos V, Molliex S, Boddaert J, Raynaud-Simon A, Durand-Zaleski I, Marcault E, Jacota M, Dahmani S, Paugam-Burtz C, Weiss E. Melatonin for prevention of postoperative delirium after lower limb fracture surgery in elderly patients (DELIRLESS): study protocol for a multicentre randomised controlled trial. BMJ Open 2021; 11:e053908. [PMID: 34952881 PMCID: PMC8713016 DOI: 10.1136/bmjopen-2021-053908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Postoperative delirium (POD) is one of the most frequent complication after surgery in elderly patients, and is associated with increased morbidity and mortality, prolonged length of stay, cognitive and functional decline leading to loss of autonomy, and important additional healthcare costs. Perioperative inflammatory stress is a key element in POD genesis. Melatonin exhibits antioxidative and immune-modulatory proprieties that are promising concerning delirium prevention, but in perioperative context literature are scarce and conflicting. We hypothesise that perioperative melatonin can reduce the incidence of POD. METHODS AND ANALYSIS The DELIRLESS trial is a prospective, national multicentric, phase III, superiority, comparative randomised (1:1) double-blind clinical trial. Among patients aged 70 or older, hospitalised and scheduled for surgery of a severe fracture of a lower limb, 718 will be randomly allocated to receive either melatonin 4 mg per os or placebo, every night from anaesthesiologist preoperative consultation and up to 5 days after surgery. The primary outcome is POD incidence measured by either the French validated translation of the Confusion Assessment Method (CAM) score for patients hospitalised in surgery, or CAM-ICU score for patients hospitalised in ICU (Intensive Care Unit). Daily delirium assessment will take place during 10 days after surgery, or until the end of hospital stay if it is shorter. POD cumulative incidence function will be compared at day 10 between the two randomised arms in a competing risks framework, using the Fine and Grey model with death as a competing risk of delirium. ETHICS AND DISSEMINATION The DELIRLESS trial has been approved by an independent ethics committee the Comité de Protection des Personnes (CPP) Sud-Est (ref CPP2020-18-99 2019-003210-14) for all study centres. Participant recruitment begins in December 2020. Results will be published in international peer-reviewed medical journals. TRIAL REGISTRATION NUMBER NCT04335968, first posted 7 April 2020. PROTOCOL VERSION IDENTIFIER N°3-0, 3 May 2021.
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Affiliation(s)
- Stéphanie Sigaut
- Anesthesiology and Intensive Care, Hôpital Beaujon, Clichy, France
- INSERM, Neurodiderot, Paris, Île-de-France, France
| | - Camille Couffignal
- Unité de recherche Clinique, Hôpital Bichat - Claude-Bernard, Paris, Île-de-France, France
| | - Marina Esposito-Farèse
- Unité de recherche Clinique, Hôpital Bichat - Claude-Bernard, Paris, Île-de-France, France
| | - Vincent Degos
- Anesthesiology and Intensive Care, University Hospital Pitié Salpêtrière, Paris, Île-de-France, France
- Faculty of Health, Sorbonne Universite, Paris, Île-de-France, France
| | - Serge Molliex
- Anesthesie Reanimation, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, Rhône-Alpes, France
| | - Jacques Boddaert
- Faculty of Health, Sorbonne Universite, Paris, Île-de-France, France
- Geriatric medicine, University Hospital Pitié Salpêtrière, Paris, Île-de-France, France
| | - Agathe Raynaud-Simon
- Geriatric Medicine, Hôpital Bichat - Claude-Bernard, Paris, Île-de-France, France
- Faculty of Health, Université de Paris, Paris, Île-de-France, France
| | | | - Estelle Marcault
- Unité de recherche Clinique, Hôpital Bichat - Claude-Bernard, Paris, Île-de-France, France
| | - Madalina Jacota
- URC HUPIFO, Hopital Ambroise-Pare, Boulogne-Billancourt, Île-de-France, France
| | - Souhayl Dahmani
- Faculty of Health, Université de Paris, Paris, Île-de-France, France
- Anesthesiology, Robert-Debré Mother-Child University Hospital, Paris, Île-de-France, France
| | | | - Emmanuel Weiss
- Anesthesiology and Intensive Care, Hôpital Beaujon, Clichy, France
- Faculty of Health, Université de Paris, Paris, Île-de-France, France
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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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Blodgett TJ, Blodgett NP. Melatonin and melatonin-receptor agonists to prevent delirium in hospitalized older adults: An umbrella review. Geriatr Nurs 2021; 42:1562-1568. [PMID: 34749057 DOI: 10.1016/j.gerinurse.2021.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/07/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Alterations in circadian rhythm play an important role in the development of delirium. In this umbrella review, we examined the efficacy of melatonin and ramelteon for delirium prevention in hospitalized older adults. METHODS Umbrella review methodology from the Joanna Briggs Institute guided the review process. Only meta-analyses were included. Risk of bias was evaluated using the AMSTAR-2 checklist. RESULTS Three meta-analyses were included in this review. The quality of studies was low-to-moderate. Two meta-analyses reported a significant reduction in delirium using melatonin or ramelteon (pooled OR and 95% confidence intervals ranged from 0.41 [0.19-0.86] to 0.63 [0.46-0.87]). Melatonergics significantly reduced delirium on medical units (OR = 0.25, 95% CI 0.07-0.88) but not surgical units (OR = 0.62, 0.16-2.43). Heterogenity was high, with I2 ranging from 72.14% to 84%. CONCLUSIONS Melatonergics appear to prevent delirium among hospitalized older adults, particularly those on medical units. Based on these results, providers may consider using melatonergics as complements to high-quality multicomponent delirium prevention.
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Affiliation(s)
- Thomas J Blodgett
- Duke University School of Nursing, 311 Trent Drive, Durham, NC, USA, 27710.
| | - Nicole P Blodgett
- Duke University School of Nursing, 311 Trent Drive, Durham, NC, USA, 27710
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Abstract
Delirium, sometimes referred to as encephalopathy, is an acute confusional state that is both common in hospitalized patients and associated with poor outcomes. For patients, families, and caregivers, delirium can be a traumatic experience. While delirium is one of the most common diagnoses encountered by the consulting neurologist, the majority of the time it will have been previously unrecognized as such by the care team. Neurologic syndromes such as dementia or aphasia can either be misdiagnosed as delirium or may coexist with it, necessitating careful neurologic assessment. Once the diagnosis of delirium has been established, a careful evaluation for predisposing and precipitating factors can help uncover modifiable contributors, which should be addressed as part of a multicomponent, primarily nonpharmacologic intervention. Importantly, delirium management, which begins with comprehensive prevention, should emphasize the humanity of the delirious patient and the challenges of caring for this vulnerable population. When considered, delirium represents an important opportunity for the neurologist to substantially enhance patient care.
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Affiliation(s)
- Sophia L Ryan
- Department of Neurology, Mount Sinai Medical Center, New York, New York
| | - Eyal Y Kimchi
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
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27
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Ukwuoma Ekeozor C, Jeyaruban D, Lasserson D. Where should patients with or at risk of delirium be treated in an acute care system? Comparing the rates of delirium in patients receiving usual care vs alternative care: A systematic review and meta-analysis. Int J Clin Pract 2021; 75:e13859. [PMID: 33236458 DOI: 10.1111/ijcp.13859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/10/2020] [Accepted: 11/22/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Delirium is an acute condition that occurs in hospitalised patients and leads to poor patient outcomes that can last long term. Therefore, the importance of prevention is undeniable and adopting new models of care for at-risk patients should be prioritised. OBJECTIVES This systematic review and meta-analysis will assess the effectiveness of different interventions designed to prevent or manage delirium in acutely unwell hospitalised patients. METHODS MEDLINE, EMBASE, PsycINFO, OpenGrey, Web of Science and reference lists of journals were searched. Eligible studies reported on incidence or duration of delirium, used a validated delirium diagnostic tool and compared an intervention to either a control or another intervention group. Meta-analyses were conducted, and GRADEpro software was used to assess the certainty of evidence. This review is registered on PROSPERO. RESULTS A total of 59 studies were included and 33 were eligible for meta-analysis. Delirium incidence was most significantly reduced by non-pharmacological multicomponent interventions compared with usual care, with pooled risk ratios of 0.57 (95% CI: 0.44 to 0.73, 10 randomised controlled trials) and 0.47 (95% CI: 0.35 to 0.64, six observational studies). Single-component interventions did not significantly reduce delirium incidence compared with usual care in seven randomised trials (risk ratio = 0.92, 95% CI: 0.81 to 1.04). The most effective single-component intervention in reducing delirium incidence was a hospital-at-home intervention (risk ratio = 0.29, 95% CI: 0.09 to 0.87). CONCLUSIONS Non-pharmacological multicomponent interventions are effective in preventing delirium; however, the same cannot be said for other interventions because of uncertain results. There is some evidence that providing multicomponent interventions in patients' homes is more effective than in a hospital setting. Therefore, researching the benefits of hospital-at-home interventions in delirium prevention is recommended.
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Affiliation(s)
| | - Darshana Jeyaruban
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Daniel Lasserson
- Health Sciences Division, University of Warwick, Coventry, UK
- Department of Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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28
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Nakamura ZM, Deal AM, Park EM, Quillen LJ, Chien SA, Stanton KE, McCabe SD, Heiling HM, Wood WA, Shea TC, Rosenstein DL. A randomized double-blind placebo-controlled trial of intravenous thiamine for prevention of delirium following allogeneic hematopoietic stem cell transplantation. J Psychosom Res 2021; 146:110503. [PMID: 33945982 PMCID: PMC8172461 DOI: 10.1016/j.jpsychores.2021.110503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine if high dose intravenous (IV) thiamine can prevent delirium during hospitalization following allogeneic HSCT. Secondarily, we evaluated the effects of high dose IV thiamine on thiamine levels and explored risk factors for delirium. METHODS Randomized, double-blind, placebo-controlled trial in patients undergoing allogeneic HSCT at a U.S. academic medical center between October 2017 and March 2020. 64 participants were randomized 1:1 to thiamine 200 mg IV three times daily for 7 days or placebo. We used the Delirium Rating Scale to assess for delirium. Delirium incidence was compared between groups using the chi-square test. Group differences in time to onset and duration of delirium were compared using the Kaplan-Meier method. Fisher's Exact and Wilcoxon Rank Sum tests were used to examine associations between pre-transplantation variables and delirium. RESULTS 61 participants were analyzed. Delirium incidence (25% vs. 21%, Chi-square (df = 1) = 0.12, p = 0.73), time to onset, duration, and severity were not different between study arms. Immediately following the intervention, thiamine levels were higher in the thiamine arm (275 vs. 73 nmol/L, t-test (df = 57) = 13.63, p < 0.0001), but not predictive of delirium. Variables associated with delirium in our sample included disease severity, corticosteroid exposure, infection, and pre-transplantation markers of nutrition. CONCLUSION High dose IV thiamine did not prevent delirium in patients receiving allogeneic HSCT. Given the multiple contributors to delirium in this population, further research regarding the efficacy of multicomponent interventions may be needed. TRIAL REGISTRATION Clinical Trials NCT03263442. FUNDING Rising Tide Foundation for Clinical Cancer Research.
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Affiliation(s)
- Zev M Nakamura
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eliza M Park
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura J Quillen
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie A Chien
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kate E Stanton
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sean D McCabe
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hillary M Heiling
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Thomas C Shea
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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29
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Sun T, Sun Y, Huang X, Liu J, Yang J, Zhang K, Kong G, Han F, Hao D, Wang X. Sleep and circadian rhythm disturbances in intensive care unit (ICU)-acquired delirium: a case-control study. J Int Med Res 2021; 49:300060521990502. [PMID: 33730927 PMCID: PMC7983249 DOI: 10.1177/0300060521990502] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE The relationships among sleep, circadian rhythm, and intensive care unit (ICU)-acquired delirium are complex and remain unclear. This study aimed to examine the pathophysiological mechanisms of sleep and circadian rhythm disturbances in patients with ICU-acquired delirium. METHODS This study included critical adult patients aged 18 to 75 years who were treated in the ICU. Twenty-four-hour polysomnography was performed and serum melatonin and cortisol levels were measured six times during polysomnography. Receiver operating characteristic curves and binomial logistic regression were used to evaluate the potential of sleep, melatonin, and cortisol as indicators of delirium in the ICU. RESULTS Patients with delirium (n = 24) showed less rapid eye movement (REM) sleep compared with patients without delirium (n = 24, controls). Melatonin levels were lower and cortisol levels were higher in the delirium group than in the control group. REM sleep, melatonin, and cortisol were significantly associated with delirium. The optimal cutoff values of REM sleep and mean melatonin and cortisol levels that predicted delirium were ≤1.05%, ≤422.09 pg/mL, and ≥212.14 ng/mL, respectively. CONCLUSIONS REM sleep, and melatonin and cortisol levels are significantly associated with the risk of ICU-acquired delirium. Improved sleep and readjustment of circadian rhythmicity may be therapeutic targets of ICU-acquired delirium.
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Affiliation(s)
- Ting Sun
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Yunliang Sun
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Xiao Huang
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Jianghua Liu
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Jiabin Yang
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Kai Zhang
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Guiqing Kong
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Fang Han
- Department of Pulmonary and Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Dong Hao
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
| | - Xiaozhi Wang
- Department of Pulmonary and Critical Care Medicine, Binzhou Medical University Hospital, Binzhou, China
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30
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Cummings KC, Keshock M, Ganesh R, Sigmund A, Kashiwagi D, Devarajan J, Grant PJ, Urman RD, Mauck KF. Preoperative Management of Surgical Patients Using Dietary Supplements: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Mayo Clin Proc 2021; 96:1342-1355. [PMID: 33741131 DOI: 10.1016/j.mayocp.2020.08.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/10/2020] [Accepted: 08/11/2020] [Indexed: 01/11/2023]
Abstract
The widespread use of complementary products poses a challenge to clinicians in the perioperative period and may increase perioperative risk. Because dietary supplements are regulated differently from traditional pharmaceuticals and guidance is often lacking, the Society for Perioperative Assessment and Quality Improvement convened a group of experts to review available literature and create a set of consensus recommendations for the perioperative management of these supplements. Using a modified Delphi method, the authors developed recommendations for perioperative management of 83 dietary supplements. We have made our recommendations to discontinue or continue a dietary supplement based on the principle that without a demonstrated benefit, or with a demonstrated lack of harm, there is little downside in temporarily discontinuing an herbal supplement before surgery. Discussion with patients in the preoperative visit is a crucial time to educate patients as well as gather vital information. Patients should be specifically asked about use of dietary supplements and cannabinoids, as many will not volunteer this information. The preoperative clinic visit provides the best opportunity to educate patients about the perioperative management of various supplements as this visit is typically scheduled at least 2 weeks before the planned procedure.
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Affiliation(s)
- Kenneth C Cummings
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, OH.
| | - Maureen Keshock
- Department of Regional Anesthesiology, Anesthesiology Institute, Cleveland Clinic, OH
| | - Ravindra Ganesh
- Division of General Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Deanne Kashiwagi
- Division of Hospital Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Jagan Devarajan
- Department of Regional Anesthesiology, Anesthesiology Institute, Cleveland Clinic, OH
| | - Paul J Grant
- Division of Hospital Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Richard D Urman
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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Lu X, Yu S, Chen G, Zheng W, Peng J, Huang X, Chen L. Insight into the roles of melatonin in bone tissue and bone‑related diseases (Review). Int J Mol Med 2021; 47:82. [PMID: 33760138 PMCID: PMC7979260 DOI: 10.3892/ijmm.2021.4915] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 02/17/2021] [Indexed: 12/18/2022] Open
Abstract
Bone‑related diseases comprise a large group of common diseases, including fractures, osteoporosis and osteoarthritis (OA), which affect a large number of individuals, particularly the elderly. The progressive destruction and loss of alveolar bone caused by periodontitis is a specific type of bone loss, which has a high incidence and markedly reduces the quality of life of patients. With the existing methods of prevention and treatment, the incidence and mortality of bone‑related diseases are still gradually increasing, creating a significant financial burden to societies worldwide. To prevent the occurrence of bone‑related diseases, delay their progression or reverse the injuries they cause, new alternative or complementary treatments need to be developed. Melatonin exerts numerous physiological effects, including inducing anti‑inflammatory and antioxidative functions, resetting circadian rhythms and promoting wound healing and tissue regeneration. Melatonin also participates in the health management of bone and cartilage. In the present review, the potential roles of melatonin in the pathogenesis and progression of bone injury, osteoporosis, OA and periodontitis are summarized. Furthermore, the high efficiency and diversity of the physiological regulatory effects of melatonin are highlighted and the potential benefits of the use of melatonin for the clinical prevention and treatment of bone‑related diseases are discussed.
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Affiliation(s)
- Xiaofeng Lu
- Department of Stomatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Shaoling Yu
- Department of Stomatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Guangjin Chen
- Department of Stomatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Wenhao Zheng
- Department of Stomatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Jinfeng Peng
- Department of Stomatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Xiaofei Huang
- Department of Stomatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Lili Chen
- Department of Stomatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
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Mengel A, Zurloh J, Boßelmann C, Brendel B, Stadler V, Sartor-Pfeiffer J, Meisel A, Fleischmann R, Ziemann U, Poli S, Stefanou MI. Delirium REduction after administration of melatonin in acute ischemic stroke (DREAMS): A propensity score-matched analysis. Eur J Neurol 2021; 28:1958-1966. [PMID: 33657679 DOI: 10.1111/ene.14792] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Poststroke delirium (PSD) comprises a common and severe complication after stroke. However, treatment options for PSD remain insufficient. We investigated whether prophylactic melatonin supplementation may be associated with reduced risk for PSD. METHODS Consecutive patients admitted to the Tübingen University Stroke Unit, Tübingen, Germany, with acute ischemic stroke (AIS), who underwent standard care between August 2017 and December 2017, and patients who additionally received prophylactic melatonin (2 mg per day at night) within 24 h of symptom onset between August 2018 and December 2018 were included. Primary outcomes were (i) PSD prevalence in AIS patients and (ii) PSD risk and PSD-free survival in patients with cerebral infarction who underwent melatonin supplementation compared to propensity score-matched (PSM) controls. Secondary outcomes included time of PSD onset and PSD duration. RESULTS Out of 465 (81.2%) patients with cerebral infarction and 108 (18.8%) transient ischemic attack (TIA) patients, 152 (26.5%) developed PSD (median time to onset [IQR]: 16 [8-32] h; duration 24 [8-40] h). Higher age, cerebral infarction rather than TIA, and higher National Institutes of Health Stroke Scale score and aphasia on admission were significant predictors of PSD. After PSM (164 melatonin-treated patients with cerebral infarction versus 164 matched controls), 42 (25.6%) melatonin-treated patients developed PSD versus 60 (36.6%) controls (odds ratio, 0.597; 95% confidence interval, 0.372-0.958; p = 0.032). PSD-free survival differed significantly between groups (p = 0.027), favoring melatonin-treated patients. In patients with PSD, no between-group differences in the time of PSD onset and PSD duration were noted. CONCLUSIONS Patients prophylactically treated with melatonin within 24 h of AIS onset had lower risk for PSD than patients undergoing standard care. Prospective randomized trials are warranted to corroborate these findings.
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Affiliation(s)
- Annerose Mengel
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Jan Zurloh
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Christian Boßelmann
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Department of Neurology and Epileptology, Hertie-Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Bettina Brendel
- Institute of Clinical Epidemiology and Applied Biometry of the University of Tübingen, Tübingen, Germany.,Department of Psychiatry and Psychotherapy, University of Tübingen, Tübingen, Germany
| | - Vera Stadler
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Jennifer Sartor-Pfeiffer
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Andreas Meisel
- Department of Neurology, Charité - University Medicine Berlin, Berlin, Germany
| | - Robert Fleischmann
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
| | - Maria-Ioanna Stefanou
- Department of Neurology & Stroke, Eberhard-Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University of Tübingen, Tübingen, Germany
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Romero N, Dube KM, Lupi KE, DeGrado JR. Evaluation of Delirium in Critically Ill Patients Prescribed Melatonin or Ramelteon. Ann Pharmacother 2021; 55:1347-1354. [PMID: 33715466 DOI: 10.1177/10600280211002054] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND An impaired sleep-wake cycle may be one factor that affects the development of delirium in critically ill patients. Several small studies suggest that exogenous melatonin or ramelteon may decrease the incidence and/or duration of delirium. OBJECTIVE To compare the effect of prophylactic administration of melatonin, ramelteon, or no melatonin receptor agonist on the development of delirium in the intensive care unit (ICU). METHODS This was a single-center, retrospective, observational cohort study of nondelirious patients in the ICU who received melatonin, ramelteon, or no melatonin receptor agonist. The primary end point was the incidence of delirium. Secondary end points included assessments of daily level of sedation and daily utilization of antipsychotic, sedative, and opioid agents. RESULTS No difference was observed in the incidence of delirium among the melatonin, ramelteon, and placebo cohorts (18.7% vs 14.3% vs 13.8%; P = 0.77). A difference was observed in the rate of agitation and sedation among the 3 groups, with the greatest observed in the melatonin cohort. Additionally, there was a difference in the use of propofol, dexmedetomidine, and opioids. Overall, there was no difference in clinical outcomes, including duration of mechanical ventilation and ICU or hospital length of stay. CONCLUSION AND RELEVANCE Therapy with melatonin, ramelteon, and no melatonin receptor agonist resulted in similar rates of delirium in a mixed ICU population. Despite significant differences in agitation, sedation, and medication utilization, there was no differences in the clinical outcomes evaluated.
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Wibrow B, Martinez FE, Ford A, Kelty E, Murray K, Ho KM, Litton E, Myers E, Anstey M. Statistical analysis plan for the Prophylactic Melatonin for Delirium in Intensive Care (ProMEDIC): a randomised controlled trial. Trials 2021; 22:7. [PMID: 33402209 PMCID: PMC7783704 DOI: 10.1186/s13063-020-04981-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 12/16/2020] [Indexed: 12/03/2022] Open
Abstract
Rationale Delirium is defined as acute organic brain dysfunction characterised by inattention and disturbance of cognition. It is common in the intensive care unit and is associated with poorer outcomes. Good quality sleep is important in the prevention and management of delirium. Melatonin is a natural hormone secreted by the pineal gland which helps in the regulation of the sleep-wake cycle. It is possible that melatonin supplementation in intensive care improves sleep and prevents delirium. Methods and design The ‘Prophylactic Melatonin for Delirium in Intensive Care’ study is a multi-centre, randomised, double-blinded, placebo-controlled trial. The primary objective of this study is to determine whether melatonin given prophylactically decreases delirium in critically ill patients. A total of 850 ICU patients have been randomised (1:1) to receive either melatonin or a placebo. Participants were monitored twice daily for symptoms of delirium. Results This paper and the attached additional files describe the statistical analysis plan (SAP) for the trial. The SAP has been developed and submitted for publication before the database has been locked and before the treatment allocation has been unblinded. The SAP contains details of analyses to be undertaken, which will be reported in the primary and secondary publications. Discussion The SAP details the analyses that will be done to avoid bias coming from knowledge of the results in advance. This trial will determine whether prophylactic melatonin administered to intensive care unit patients helps decrease the rate and the severity of delirium. Trial registration Australian and New Zealand Clinical Trial Registry (ANZCTR) ACTRN1261600043647, registration date: 06 April 2016. WHO Trial Number – U1111-1175-1814
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Affiliation(s)
- Bradley Wibrow
- Intensive Care Unit, Sir Charles Gairdner Hospital, University of WA, Perth, WA, Australia.
| | - F Eduardo Martinez
- Intensive Care Unit, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andrew Ford
- Dept. of Psychiatry, Royal Perth Hospital, Perth, WA, Australia
| | - Erin Kelty
- Centre for Applied Statistics, University of WA, Perth, WA, Australia
| | - Kevin Murray
- Centre for Applied Statistics, University of WA, Perth, WA, Australia
| | - Kwok M Ho
- Intensive Care Unit, Royal Perth Hospital, Medical School, University of Western Australia & Murdoch University, Perth, Australia
| | - Edward Litton
- St. John of God Hospital Subiaco, Intensive Care Unit, Fiona Stanley Hospital, Perth, WA, Australia
| | - Erina Myers
- Intensive Care Unit, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Matthew Anstey
- Intensive Care Unit, Sir Charles Gairdner Hospital, Curtin University, Perth, WA, Australia
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Garcez FB, Avelino-Silva TJ, Castro REVD, Inouye SK. Delirium in older adults. GERIATRICS, GERONTOLOGY AND AGING 2021. [DOI: 10.53886/gga.e0210032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
This narrative review provides a broad examination of the most current concepts on the etiopathogenesis, diagnosis, prevention, and treatment of delirium, an acute neuropsychiatric syndrome characterized by fluctuating changes in cognition and consciousness. With the interaction of underlying vulnerability and severity of acute insults, delirium can occur at any age but is particularly frequent in hospitalized older adults. Delirium is also associated with numerous adverse outcomes, including functional impairment, cognitive decline, increased healthcare costs, and death. Its diagnosis is based on clinical and cognitive assessments, preferably following systematized detection instruments, such as the Confusion Assessment Method (CAM). Delirium and its consequences are most effectively fought using multicomponent preventive interventions, like those proposed by the Hospital Elder Life Program (HELP). When prevention fails, delirium management is primarily based on the identification and reversal of precipitating factors and the non-pharmacological control of delirium symptoms. Pharmacological interventions in delirium should be restricted to cases of dangerous agitation or severe psychotic symptoms.
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Khaing K, Nair BR. Melatonin for delirium prevention in hospitalized patients: A systematic review and meta-analysis. J Psychiatr Res 2021; 133:181-190. [PMID: 33348252 DOI: 10.1016/j.jpsychires.2020.12.020] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/17/2020] [Accepted: 12/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Melatonin, a pineal gland hormone is reported to have a protective effect against delirium. This systematic review and meta-analysis explores the effect of melatonin and melatonin receptor agonist, ramelteon on delirium prevention in adult hospitalized patients. METHODS Randomized Controlled trials of melatonin/ramelteon published up to May 7, 2020 were identified from MEDLINE, PREMEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled trials, PubMed, and Google Scholar. The primary outcome was delirium incidence. The secondary outcomes were sleep quality, sedation score, sedatives requirement, delirium duration, length of hospital stay, length of Intensive Care Unit (ICU) stay, mortality and adverse events. A meta-analysis with a random-effects models was performed. Estimates were presented as Risk Ratio (RR) or Mean Differences (MD) with 95% Confidence Interval (CI). FINDINGS Fourteen studies with 1712 participants were included. Melatonin/ramelteon significantly reduced delirium incidence (RR 0·61, 95% CI 0·42-0·89, p 0·009) with risk reduction of 49% in surgical patients and 34% in ICU patients. Non-significant reduction was found in medical patients. Melatonin/ramelteon were associated with improvement in sleep quality, increased sedation score and lower sedatives consumption. However, they did not reduce delirium duration, length of hospital stay, length of ICU stay and mortality. Hallucinations, nightmares and gastrointestinal disorders were prevalent in melatonin group. INTERPRETATION Melatonin/ramelteon are associated with reduction in delirium incidence in hospitalized patients. However, this effect seems confined to surgical and ICU patients. The optimum dosage and formulation of melatonin, and treatment duration remain uncleared and open to further studies with larger sample sizes.
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Affiliation(s)
- Kay Khaing
- Hunter New England Health, 2 Lookout Road, New Lambton Heights, 2305, NSW, Australia.
| | - Balakrishnan R Nair
- University of Newcastle, The Lodge, John Hunter Hospital Campus, New Lambton Heights, 2305, NSW, Australia
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Jaiswal SJ, Kang DY, Wineinger NE, Owens RL. Objectively measured sleep fragmentation is associated with incident delirium in older hospitalized patients: Analysis of data collected from an randomized controlled trial. J Sleep Res 2020; 30:e13205. [PMID: 33051948 DOI: 10.1111/jsr.13205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 08/18/2020] [Accepted: 08/31/2020] [Indexed: 11/30/2022]
Abstract
Delirium may lead to poor outcomes in hospitalized older adults, and sleep deprivation may contribute to its pathogenesis. Thus, we sought to measure sleep duration and fragmentation using wrist-worn actigraphy in older, hospitalized patients with and without delirium, and to determine if actigraphy-based parameters could be used to predict delirium prior to clinical recognition. We conducted a secondary analysis of data from a recent, randomized clinical trial aimed at preventing inpatient delirium. Participants (n = 70) were aged ≥ 65 years admitted to an internal medicine service. Delirium was defined by the Confusion Assessment Method, or altered mental status identified by a clinician. Sleep measurements were actigraphy-based, and included total sleep time, median sleep bout duration and other measures of sleep fragmentation. We found that total sleep duration was similar between patients with (n = 17) and without (n = 53) delirium (mean 384.9 ± SD 162.7 versus mean 456.6 ± SD 135.8 min; p = .081). Mean sleep bout times were shorter in delirious versus never-delirious patients (median 6.1 [interquartile range 4.3-8.9] versus 7.9 [interquartile range 5.7-11.3] min, p = .048). Patients with delirium had more short sleep bouts (< 10 min) and fewer longer sleep bouts (> 30 min) compared with those without delirium. Increased sleep fragmentation was present prior to the clinical recognition of delirium. Overall, delirium was associated with increased sleep fragmentation detected by actigraphy, and sleep fragmentation might be useful as a biomarker for delirium prediction in the future.
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Affiliation(s)
- Stuti J Jaiswal
- The Scripps Research Institute, La Jolla, CA, USA.,Division of Hospital Medicine, Scripps Clinic, La Jolla, CA, USA
| | - Dae Y Kang
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego School of Medicine, La Jolla, CA, USA
| | | | - Robert L Owens
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego School of Medicine, La Jolla, CA, USA
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Pharmacologic interventions for prevention of delirium in hospitalized older people: A meta-analysis. Arch Gerontol Geriatr 2020; 90:104171. [DOI: 10.1016/j.archger.2020.104171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/25/2020] [Accepted: 06/29/2020] [Indexed: 12/17/2022]
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Jobanputra AM, Scharf MT, Androulakis IP, Sunderram J. Circadian Disruption in Critical Illness. Front Neurol 2020; 11:820. [PMID: 32849248 PMCID: PMC7431488 DOI: 10.3389/fneur.2020.00820] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/30/2020] [Indexed: 12/12/2022] Open
Abstract
Circadian rhythms play a vital role in metabolic, hormonal, and immunologic function and are often disrupted in patients in the ICU. Circadian rhythms modulate the molecular machinery that responds to injury and illness which can impact recovery. Potential factors contributing to the alteration in circadian rhythmicity in intensive care unit (ICU) patients include abnormal lighting, noise, altered feeding schedules, extensive patient care interactions and medications. These alterations in circadian rhythms in ICU patients may affect outcomes and therefore, normalization of circadian rhythmicity in critically ill patients may be an important part of ICU care.
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Affiliation(s)
- Aesha M Jobanputra
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Matthew T Scharf
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States.,Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Ioannis P Androulakis
- Biomedical Engineering Department, Rutgers University, Piscataway, NJ, United States.,Chemical and Biochemical Engineering Department, Rutgers University, Piscataway, NJ, United States.,Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Jag Sunderram
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
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Bala R, Singh V, Rajender S, Singh K. Environment, Lifestyle, and Female Infertility. Reprod Sci 2020; 28:617-638. [DOI: 10.1007/s43032-020-00279-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/24/2020] [Indexed: 01/01/2023]
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Fernandez Cuartas C, Correa Ordoñez I, Davis MP. Nonantipsychotics/Nonbenzodiazepines in the Management of Agitated Delirium #397. J Palliat Med 2020; 23:1127-1129. [PMID: 32790570 DOI: 10.1089/jpm.2020.0252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Farasat S, Dorsch JJ, Pearce AK, Moore AA, Martin JL, Malhotra A, Kamdar BB. Sleep and Delirium in Older Adults. CURRENT SLEEP MEDICINE REPORTS 2020; 6:136-148. [PMID: 32837850 PMCID: PMC7382993 DOI: 10.1007/s40675-020-00174-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Purpose of Review Poor sleep and delirium are common in older patients but recognition and management are challenging, particularly in the intensive care unit (ICU) setting. The purpose of this review is to highlight current research on these conditions, their inter-relationship, modes of measurement, and current approaches to management. Recent Findings Sleep deprivation and delirium are closely linked, with shared clinical characteristics, risk factors, and neurochemical abnormalities. Acetylcholine and dopamine are important neurochemicals in the regulation of sleep and wakefulness and their dysregulation has been implicated in development of delirium. In the hospital setting, poor sleep and delirium are associated with adverse outcomes; non-pharmacological interventions are recommended, but tend to be resource intensive and hindered by a lack of reliable sleep measurement tools. Delirium is easier to identify, with validated tools available in both ICU and non-ICU settings; however, an optimal treatment approach remains unclear. Antipsychotics are used widely to prevent and treat delirium, although the efficacy data are equivocal. Bundled non-pharmacologic approaches represent a promising framework for prevention and management. Summary Poor sleep and delirium are common problems in older patients. While these phenomena appear linked, a causal relationship is not clearly established. At present, there are no established sleep-focused guidelines for preventing or treating delirium. Novel interventions are needed that address poor sleep and delirium, particularly in older adults.
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Affiliation(s)
- Sadaf Farasat
- Division of Geriatrics and Gerontology, University of California San Diego, 9350 Campus Point Drive, La Jolla, CA 92037 USA
| | - Jennifer J Dorsch
- Johns Hopkins Medicine, Baltimore, MD USA.,Johns Hopkins Medicine, Howard County General Hospital, 5755 Cedar Ln, Columbia, MD 21044 USA
| | - Alex K Pearce
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
| | - Alison A Moore
- Division of Geriatrics and Gerontology, University of California San Diego, 9500 Gilman Drive, MC 0665, La Jolla, CA 92093-0665 USA
| | - Jennifer L Martin
- VA Greater Los Angeles Healthcare System, 16111 Plummer St. (11E), North Hills, CA 91343 USA.,David Geffen School of Medicine at the University of California, Los Angeles, CA USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
| | - Biren B Kamdar
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego School of Medicine, 9300 Campus Point Drive #7381, La Jolla, CA 92037-7381 USA
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A phase II study of ramelteon for the prevention of postoperative delirium in elderly patients undergoing gastrectomy. Surg Today 2020; 50:1681-1686. [PMID: 32642823 DOI: 10.1007/s00595-020-02073-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/03/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE The growing number of cases of gastric cancer being diagnosed in elderly patients highlights the importance of preventing postoperative delirium. This phase II study aimed to evaluate the efficacy of perioperative treatment with ramelteon for preventing postoperative delirium in elderly patients undergoing gastrectomy. METHODS This study was designed as a single-institute prospective phase II study. Patients ≥ 75 years old were eligible. Ramelteon 8 mg/day was administered from 8 days before the operation until discharge. Postoperative delirium was evaluated using the Confusion Assessment Method-Intensive Care Unit flow sheet. RESULTS Between September 2015 and July 2017, a total of 83 patients were enrolled, 76 of whom were eligible and included in the analysis. Postoperative delirium was observed in four patients (5%) (60% confidence interval: 3.0-8.7). The upper margin of the confidence interval was lower than the prespecified threshold of 13%; therefore, the null hypothesis was rejected. CONCLUSION This phase II study suggested that the perioperative administration of ramelteon is safe and feasible for preventing postoperative delirium in elderly patients undergoing gastrectomy. Trial registration This study was registered at UMIN (UMIN 000018697).
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Nakamura ZM, Deal AM, Rosenstein DL, Quillen LJ, Chien SA, Wood WA, Shea TC, Park EM. Design of a randomized placebo controlled trial of high dose intravenous thiamine for the prevention of delirium in allogeneic hematopoietic stem cell transplantation. Contemp Clin Trials 2020; 95:106076. [PMID: 32619524 DOI: 10.1016/j.cct.2020.106076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Delirium is a highly prevalent and preventable neuropsychiatric condition with major health consequences. Thiamine deficiency is a well-established cause of delirium in those with chronic, severe alcoholism, but there remains an underappreciation of its significance in non-alcoholic populations, including patients with cancer. Treatment of suspected thiamine-related mental status changes with high dose intravenous (IV) thiamine has preliminary evidence for improving a variety of cognitive symptoms in oncology inpatient settings but has never been studied for the prevention of delirium in any population. OBJECTIVES The primary objective of this clinical trial is to determine if high dose IV thiamine can prevent delirium in patients receiving allogeneic hematopoietic stem cell transplantation (HSCT) for treatment of cancer. Secondary objectives are to determine if thiamine status is predictive of delirium onset and if high dose IV thiamine can attenuate the deleterious impact of delirium on health-related quality of life (HRQOL), functional status, and long-term neuropsychiatric outcomes. METHODS In this phase II study, we are recruiting 60 patients undergoing allogeneic HSCT, randomizing them to treatment with high dose IV thiamine (n = 30) versus placebo (n = 30), and systematically evaluating all participants for delirium and related comorbidities. We use the Delirium Rating Scale to measure the severity and duration of delirium during hospitalization for HSCT. We obtain thiamine levels weekly during the transplantation hospitalization. We assess HRQOL, functional status, depression, post-traumatic stress symptoms, and cognitive function prior to and at one, three, and six months after transplantation.
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Affiliation(s)
- Zev M Nakamura
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura J Quillen
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie A Chien
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Thomas C Shea
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eliza M Park
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Shang Y, Pan C, Yang X, Zhong M, Shang X, Wu Z, Yu Z, Zhang W, Zhong Q, Zheng X, Sang L, Jiang L, Zhang J, Xiong W, Liu J, Chen D. Management of critically ill patients with COVID-19 in ICU: statement from front-line intensive care experts in Wuhan, China. Ann Intensive Care 2020; 10:73. [PMID: 32506258 PMCID: PMC7275657 DOI: 10.1186/s13613-020-00689-1] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 05/25/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The ongoing coronavirus disease 2019 (COVID-2019) pandemic has swept all over the world, posing a great pressure on critical care resources due to large number of patients needing critical care. Statements from front-line experts in the field of intensive care are urgently needed. METHODS Sixteen front-line experts in China fighting against the COVID-19 epidemic in Wuhan were organized to develop an expert statement after 5 rounds of expert seminars and discussions to provide trustworthy recommendation on the management of critically ill COVID-19 patients. Each expert was assigned tasks within their field of expertise to provide draft statements and rationale. Parts of the expert statement are based on epidemiological and clinical evidence, without available scientific evidences. RESULTS A comprehensive document with 46 statements are presented, including protection of medical personnel, etiological treatment, diagnosis and treatment of tissue and organ functional impairment, psychological interventions, immunity therapy, nutritional support, and transportation of critically ill COVID-19 patients. Among them, 5 recommendations were strong (Grade 1), 21 were weak (Grade 2), and 20 were experts' opinions. A strong agreement from voting participants was obtained for all recommendations. CONCLUSION There are still no targeted therapies for COVID-19 patients. Dynamic monitoring and supportive treatment for the restoration of tissue vascularization and organ function are particularly important.
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Affiliation(s)
- You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun Pan
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xianghong Yang
- Department of Critical Care Medicine, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Ming Zhong
- Department of Critical Care Medicine, Zhongshan Hospital Fudan University, Shanghai, China
| | - Xiuling Shang
- Department of Critical Care Medicine, Fujian Provincial Hospital, Fujian Provincial Center for Critical Care Medicine, Fuzhou, China
| | - Zhixiong Wu
- Department of Critical Care Medicine, Huadong Hospital, Shanghai, China
| | - Zhui Yu
- Department of Critical Care Medicine, Renmin Hospital, Wuhan University, Wuhan, China
| | - Wei Zhang
- Emergency Department, the 900th Hospital of Joint Service Corps of Chinese PLA, Fuzhou, China
| | - Qiang Zhong
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xia Zheng
- Department of Critical Care Medicine, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Ling Sang
- Department of Critical Care Medicine, The 1st Affiliated Hospital of GuangZhou Medical University, GuangZhou Institute of Respiratory Health, Guangzhou, China
| | - Li Jiang
- Department of Critical Care Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jiancheng Zhang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Xiong
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiao Liu
- Department of Critical Care Medicine, Shanghai Jiaotong University, School of Medicine, Ruijin Hospital North, No. 197 Ruijin 2nd Road, Huangpu District, Shanghai, 201801, China
| | - Dechang Chen
- Department of Critical Care Medicine, Shanghai Jiaotong University, School of Medicine, Ruijin Hospital North, No. 197 Ruijin 2nd Road, Huangpu District, Shanghai, 201801, China.
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Asleson DR, Chiu AW. Melatonin for delirium prevention in acute medically ill, and perioperative geriatric patients. Aging Med (Milton) 2020; 3:132-137. [PMID: 32666028 PMCID: PMC7338699 DOI: 10.1002/agm2.12112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/17/2020] [Accepted: 04/23/2020] [Indexed: 12/14/2022] Open
Abstract
Delirium is a challenging neuropsychiatric ailment that has a negative impact on morbidity and mortality and is difficult to treat once it has developed. The purpose of this review was to analyze the efficacy of melatonin in the prevention of delirium in hospitalized geriatric patients in the acute medically ill and perioperative wards. The databases searched included PubMed (1946 to February 12, 2020), CINAHL (1982 to February 12, 2020), EMBASE (1974 to February 12, 2020), and Web of Science (1900 to February 12, 2020) using search terms related to melatonin, delirium, and prevention. Meta-analyses, randomized controlled trials, and observational studies were included. We excluded publications pertaining to the intensive care unit or oncology, case reports/series, and those not in English. Seven full-text publications were included for qualitative analysis. Patient comorbidities, patient medications, melatonin dosing, dosing regimens, and duration of treatment varied between the studies, which yielded heterogeneous results. Overall, this literature review yielded four studies that showed positive results and three that showed negative results for delirium prevention. The current data for the use of melatonin in delirium is conflicting. This area requires further research of more homogeneous studies with larger sample sizes.
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Affiliation(s)
- Demi R. Asleson
- Faculty of Pharmaceutical SciencesThe University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Ada W. Chiu
- Surrey Memorial HospitalFraser Health AuthoritySurreyBritish ColumbiaCanada
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Adams AD, Pepin MJ, Brown JN. The role of suvorexant in the prevention of delirium during acute hospitalization: A systematic review. J Crit Care 2020; 59:1-5. [PMID: 32480359 DOI: 10.1016/j.jcrc.2020.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/24/2020] [Accepted: 05/17/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess the efficacy and safety of suvorexant for the prevention of delirium during acute hospitalization. MATERIALS AND METHODS Pubmed (1946 to December 2019) and Embase (1947 to December 2019) were queried using the search term combination: delirium, confusion, cognitive defect, encephalopathy, critically ill patient, critical illness, or hospitalization and suvorexant or orexin receptor antagonist. Studies analyzed for relevance evaluated clinical outcomes of patients treated with suvorexant for prevention of delirium. Studies appropriate to the objective were evaluated, including two randomized controlled trials and four retrospective studies. RESULTS In acutely hospitalized patients, treatment with suvorexant 15 to 20 mg alone or in combination with ramelteon resulted in a reduction in development of delirium, time until delirium onset, and length of hospital stay. When assessed, suvorexant was well tolerated and adverse effects were no worse than placebo. CONCLUSION Based on the reviewed literature, suvorexant has shown positive outcomes in the prevention of delirium during an acute hospitalization. Larger trials comparing the efficacy of suvorexant to other sleep modulating options are necessary to further delineate its role for the prevention of delirium.
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Affiliation(s)
- Aaron D Adams
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC 27705, USA; Pharmacy Service, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC 27705, USA
| | - Marc J Pepin
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC 27705, USA; Pharmacy Service, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC 27705, USA
| | - Jamie N Brown
- Pharmacy Service, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC 27705, USA.
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Zhu Y, Jiang Z, Huang H, Li W, Ren C, Yao R, Wang Y, Yao Y, Li W, Du B, Xi X. Assessment of Melatonergics in Prevention of Delirium: A Systematic Review and Meta-Analysis. Front Neurol 2020; 11:198. [PMID: 32318011 PMCID: PMC7154101 DOI: 10.3389/fneur.2020.00198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/05/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Delirium is a commonly found comorbidity in hospitalized patients and is associated with adverse outcomes. Melatonin is an endogenous hormone that exerts multiple biological effects, mainly in regulating diurnal rhythms and in inflammatory process and immune responses. We aimed to assess the efficacy of exogenous melatonergics in the prevention of delirium. Methods: We conducted a search to identify relevant randomized controlled studies (RCTs) in PubMed, Cochrane Library, and EMBASE databases that had been published up to December 2019. Hospitalized adult patients administered melatonergics were included. The primary outcome measure was the incidence of delirium. The secondary outcome measure was the length of stay in intensive care unit (ICU-LOS). The pooled effects were analyzed as the risk ratio (RR) for delirium incidence, weighted mean difference (WMD) for ICU-LOS, and 95% confidence intervals (CIs). Results: Nine RCTs with 1,210 patients were included. The forest plots showed that melatonergics were associated with a decreasing incidence of delirium (RR, 0.51; 95% CI, 0.30–0.85; I2 = 70%; p = 0.01). There was no significant difference in ICU-LOS (WMD, −0.08; 95% CI, −0.19–0.03; I2 = 0; p = 0.17). Conclusion: Administration of exogenous melatonergics to hospitalized patients seems to be associated with a decreasing incidence of delirium. PROSPERO registration number: CRD42019138863.
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Affiliation(s)
- Yibing Zhu
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
| | - Zhiming Jiang
- Department of Respiratory Medicine, Qilu Hospital of Shandong University, Jinan, China.,School of Medicine, Shandong University, Jinan, China.,Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Huibin Huang
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.,Department of Critical Care Medicine, Beijing Tsinghua Chang Gung Hospital, Beijing, China
| | - Wen Li
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
| | - Chao Ren
- School of Medicine, Nankai University, Tianjin, China.,Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China.,State Key Laboratory of Kidney Disease, The Chinese PLA General Hospital, Beijing, China
| | - Renqi Yao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China.,Department of Burn Surgery, Changhai Hospital, The Second Military Medical University, Shanghai, China
| | - Yang Wang
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongming Yao
- School of Medicine, Nankai University, Tianjin, China.,Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China.,State Key Laboratory of Kidney Disease, The Chinese PLA General Hospital, Beijing, China
| | - Wei Li
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiuming Xi
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing, China
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Baumgartner L, Lam K, Lai J, Barnett M, Thompson A, Gross K, Morris A. Effectiveness of Melatonin for the Prevention of Intensive Care Unit Delirium. Pharmacotherapy 2020; 39:280-287. [PMID: 30663785 DOI: 10.1002/phar.2222] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVE Intensive care unit (ICU) delirium is an acute brain dysfunction that has been associated with increased mortality, prolonged ICU and hospital lengths of stay, and development of post-ICU cognitive impairment. Melatonin may help to restore sleep and reduce the occurrence of ICU delirium. The purpose of this study was to evaluate the effectiveness of melatonin for the prevention of ICU delirium in critically ill adults. DESIGN Retrospective, observational cohort study. SETTING Large academic medical center. PATIENTS A total of 232 adults were included who were admitted to the medical-surgical or cardiac ICUs between 2013 and 2017 who had a negative Confusion Assessment Method for the ICU (CAM-ICU). Of those, patients who received melatonin for at least 48 hours were included in the melatonin group (n=117). Patients were included in the control group if they were admitted to the ICU for at least 4 days (average time of melatonin initiation) and did not receive melatonin or antipsychotics within the first 4 days of their ICU stay (n=115). MEASUREMENTS AND MAIN RESULTS The primary outcome was development of delirium, which was assessed by using the CAM-ICU twice daily by nursing staff. The development of delirium was significantly lower in the melatonin group: 9 (7.7%) versus 28 (24.3%) patients (p = 0.001). This finding remained significant in multivariate logistic models controlling for age, sex, history of hypertension, need for emergent surgery, Acute Physiology and Chronic Health Evaluation II score, mechanical ventilation, ICU length of stay, dexmedetomidine use, and benzodiazepine use. For those patients who developed delirium, patients in the control group had, on average, 20.9 delirium-free days without coma in 28 days compared with 19.9 days in the melatonin group (p = 0.72). In the melatonin group, melatonin was used for a mean ± SD of 6.3 ± 7.9 days, with a median dose of 3.5 mg/night (range: 1-10 mg). CONCLUSION The development of ICU delirium was significantly lower in the melatonin group compared with that in the control group. To our knowledge, this is one of the only studies that has examined the use of melatonin for the prevention of ICU delirium. Melatonin may be a promising agent for the prevention of ICU delirium; however, a randomized study is needed to further validate its efficacy.
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Affiliation(s)
- Laura Baumgartner
- Touro University California College of Pharmacy, Vallejo, California.,University of California San Francisco Medical Center, San Francisco, California
| | - Kalvin Lam
- Touro University California College of Pharmacy, Vallejo, California
| | - Jonathan Lai
- Touro University California College of Pharmacy, Vallejo, California
| | - Mitch Barnett
- Touro University California College of Pharmacy, Vallejo, California
| | - Ashley Thompson
- University of California San Francisco Medical Center, San Francisco, California
| | - Kendall Gross
- University of California San Francisco Medical Center, San Francisco, California
| | - Amanda Morris
- University of California San Francisco Medical Center, San Francisco, California
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Ng KT, Teoh WY, Khor AJ. The effect of melatonin on delirium in hospitalised patients: A systematic review and meta-analyses with trial sequential analysis. J Clin Anesth 2020; 59:74-81. [DOI: 10.1016/j.jclinane.2019.06.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/11/2019] [Accepted: 06/24/2019] [Indexed: 11/30/2022]
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