Delirium: where do we stand?

Efficacy and safety of haloperidol versus atypical antipsychotic medications in the treatment of delirium

BACKGROUND

Most previous studies on the efficacy of antipsychotic medication for the treatment of delirium have reported that there is no significant difference between typical and atypical antipsychotic medications. It is known, however, that older age might be a predictor of poor response to antipsychotics in the treatment of delirium. The objective of this study was to compare the efficacy and safety of haloperidol versus three atypical antipsychotic medications (risperidone, olanzapine, and quetiapine) for the treatment of delirium with consideration of patient age.

METHODS

This study was a 6-day, prospective, comparative clinical observational study of haloperidol versus atypical antipsychotic medications (risperidone, olanzapine, and quetiapine) in patients with delirium at a tertiary level hospital. The subjects were referred to the consultation-liaison psychiatric service for management of delirium and were screened before enrollment in this study. A total of 80 subjects were assigned to receive either haloperidol (N = 23), risperidone (N = 21), olanzapine (N = 18), or quetiapine (N = 18). The efficacy was evaluated using the Korean version of the Delirium Rating Scale-Revised-98 (DRS-K) and the Korean version of the Mini Mental Status Examination (K-MMSE). The safety was evaluated by the Udvalg Kliniske Undersogelser side effect rating scale.

RESULTS

There were no significant differences in mean DRS-K severity or K-MMSE scores among the four groups at baseline. In all groups, the DRS-K severity score decreased and the K-MMSE score increased significantly over the study period. However, there were no significant differences in the improvement of DRS-K or K-MMSE scores among the four groups. Similarly, cognitive and non-cognitive subscale DRS-K scores decreased regardless of the treatment group. The treatment response rate was lower in patients over 75 years old than in patients under 75 years old. Particularly, the response rate to olanzapine was poorer in the older age group. Fifteen subjects experienced a few adverse events, but there were no significant differences in adverse event profiles among the four groups.

CONCLUSIONS

Haloperidol, risperidone, olanzapine, and quetiapine were equally efficacious and safe in the treatment of delirium. However, age is a factor that needs to be considered when making a choice of antipsychotic medication for the treatment of delirium.

TRIAL REGISTRATION

Clinical Research Information Service, Republic of Korea, (http://cris.nih.go.kr/cris/en/search/basic_search.jsp, Registered Trial No. KCT0000632).

Risperidone versus olanzapine for the treatment of delirium

OBJECTIVE

This study compared the effectiveness of risperidone and olanzapine in the treatment of delirium.

METHODS

This was a 7-day, randomized, comparative clinical trial of risperidone and olanzapine in patients with delirium. The primary outcome measure was the Delirium Rating Scale-Revised-98 (DRS-R-98).

RESULTS

We enrolled 32 subjects (median age, 70 years). Significant within-group improvements in the DRS-R-98 scores over time were observed at every time point in both treatment groups; however, differences in the change of the DRS-R-98 score from baseline were not significant between the treatment groups. On the first day after drug treatment, there was a trend toward greater improvement in the DRS-R-98 score in the olanzapine group compared with the risperidone group, but it did not reach statistical significance (p = 0.076). The response rates did not differ significantly between the two groups (risperidone group: 64.7%, olanzapine group: 73.3%). However, the response to risperidone was significantly poorer in patients >or=70 years of age compared with those aged <70 years. There was no significant difference in the safety profiles, including extrapyramidal symptoms (EPSs), between the two groups.

CONCLUSION

Risperidone and olanzapine were equally effective in reducing delirium symptoms. The response to risperidone was poorer in the older age group.

Delirium: sifting through the confusion

Delirium is commonly encountered in the hospital setting, particularly in the intensive care unit. However, the diagnosis is often missed, due in part to the nature of the illness, fluctuating levels of consciousness, and varied presentation. Even when it is recognized, delirium can be hard to manage, with multiple factors contributing to its course. In this article, we review the latest information regarding the underlying mechanisms of the syndrome and treatment options available. This is accomplished by examining two complex cases encountered at a university medical center-based psychosomatic service.