Use of Suvorexant and Antipsychotics in the Treatment of Delirium After Infectious Diseases: A Retrospective Study

Pharmacologic Treatment Strategies for Delirium in Hospitalized Adults: Past, Present, and Future

Despite the use of multidomain prevention strategies, delirium still frequently occurs in hospitalized adults. With delirium often associated with undesirable symptoms and deleterious outcomes, including cognitive decline, treatment is important. Risk-factor reduction and the protocolized use of multidomain, nonpharmacologic bundles remain the mainstay of delirium treatment. There is a current lack of strong evidence to suggest any pharmacologic intervention to treat delirium will help resolve it faster, reduce its symptoms (other than agitation), facilitate hospital throughput, or improve post-hospital outcomes including long-term cognitive function. With the exception of dexmedetomidine as a treatment of severe delirium-associated agitation in the ICU, current practice guidelines do not recommend the routine use of any pharmacologic intervention to treat delirium in any hospital population. Future research should focus on identifying and evaluating new pharmacologic delirium treatment interventions and addressing key challenges and gaps surrounding delirium treatment research.

Orexin receptor antagonists versus antipsychotics for the management of delirium in intensive care unit patients with cardiovascular disease: A retrospective observational study

OBJECTIVE

Although antipsychotics are often used in the pharmacological treatment of delirium, recent reports suggest the efficacy of orexin receptor antagonists. This study investigated whether orexin receptor antagonists could be a possible treatment option for delirium.

METHOD

A nonblinded nonrandomized routine clinical treatment was performed. Patients treated in intensive care units (ICU) for cardiovascular disease and receiving psychiatric intervention were studied retrospectively. The scores from the Intensive Care Delirium Screening Checklist (ICDSC) were compared between patients treated with orexin receptor antagonists and those treated with antipsychotics.

RESULTS

The mean (standard deviation) ICDSC scores were 4.5 (1.8) at day -1 and 2.6 (2.6) at day 7 for orexin receptor antagonist group (n = 25) and 4.6 (2.4) at day -1 and 4.1 (2.2) at day 7 for antipsychotic group (n = 28). The orexin receptor antagonist group showed significantly lower ICDSC scores than the antipsychotic group (p = 0.021).

CONCLUSION

While precise efficacy cannot be determined from our retrospective, observational, and uncontrolled pilot study, this analysis encourages a future double-blind randomized placebo-controlled trial of orexin-antagonists for delirium treatment.

Sleep Immune Cross Talk and Insomnia

Sleep and immunity have bidirectional relationships. In this chapter, we review the links between sleep and immunity, focusing on immune changes occurring in the insomnia disorder. During physiological sleep, there is a decrease of pro-inflammatory cytokines (IL-1, IL-6 and TNF-α) and a decrease of anti-inflammatory cytokines (IL-4, IL-10). Examinations of ratios of pro-inflammatory and anti-inflammatory cytokines allow to identify rather a pro-inflammatory activity at the beginning of the night and confirm then anti-inflammatory during the second part of the night. Immune cells, as NK-cells, decrease in the blood, due to their migration to secondary lymphoid organs, but their activity increases. Inversely, a short sleep duration appears associated with increased inflammatory processes and increased risk of infection.Only few studies have investigated changes in immunity in patients with insomnia disorder. These studies suggest that insomnia disorder is related to deregulation of the immune system, with an increase in the level of pro-inflammatory cytokines and change in rate of secretion and a decrease in the level of lymphocyte. Insomnia treatments, particularly cognitive behavioral therapy (CBT-I), seems to have a restorative effect not only on sleep, but also on the associated inflammation. Melatonin also seems to reduce inflammation in patients suffering from insomnia disorder.More studies are necessary to better understand the pathophysiology of changes in immune system in patients suffering from insomnia disorders and their clinical implications.