[Non-withdrawal-related delirium : Evidence on prevention and therapy]

[Delirium in the context of intensive care medicine-Part 2: diagnosis, prevention and treatment]

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.

[Delirium in the context of intensive care medicine-Part 1: epidemiology, definitions, pathophysiology]

The prevalence of delirium syndromes is high, they are often underdiagnosed and therefore medically as well as economically highly relevant syndromes due to the long-term sequelae. In the majority of cases, delirium has a multifactorial etiology, which is why a comprehensive search for the cause is of highest priority. Surgery, administration of potentially proinflammatory drugs as well as the intensive care environment, including the underlying disease and drugs used, represent relevant etiological factors. Pathophysiology and psychopathology are complex and vary depending on the etiological factors present. Prominent impairment of attention and consciousness are central symptoms of delirium allowing the differentiation from important differential diagnoses, such as encephalopathy, depression, psychosis and dementia.

[Treatment with psychotropic agents in patients with dementia and delirium : Gap between guideline recommendations and treatment practice]

BACKGROUND AND OBJECTIVES

Psychiatric symptoms in dementia and delirium are associated with a substantially reduced quality of life of patients and their families and often challenging for professionals. Pharmacoepidemiological surveys have shown that, in particular, patients living in nursing homes receive prescriptions of psychotropic agents in significant higher frequency than recommended by current guidelines. This article focuses on a critical appraisal of this gap from the point of view of German healthcare services.

MATERIAL AND METHODS

Narrative review with special reference to the German dementia guideline from 2016 and recently published practice guidelines for delirium in old age in German and English language.

RESULTS

The indications for use of psychotropic agents, especially antipsychotics, are defined narrowly in the German dementia guideline. According to this guideline for several psychopathological symptoms evidence based recommendations cannot be given, currently. For delirium several practice guidelines related to different treatment settings have been published recently. Comparable to the German dementia guideline they recommend general medical interventions and nonpharmacological treatment as first line measures and the use of psychotropic agents only under certain conditions. These guidelines differ to some extent regarding the strength of recommendation for psychopharmacological treatment.

CONCLUSION

The guidelines discussed here advocate well-founded a cautious prescription of psychotropic agents in patients with dementia and delirium. This contrasts to everyday practice which is characterized by significantly higher prescription rates. This gap may explained partially by a lack of evidence-based recommendations regarding certain psychopathological symptoms. Most notably, however, epidemiological data disclose an unacceptable rate of hazardous overtreatment with psychotropic agents, especially in long-term care of persons with dementia. In this situation counteractive measures by consequent implementation of the principles of good clinical practice in geriatrics are required urgently.