Emergent Antidepressant Discontinuation Syndrome Misdiagnosed as Delirium in the ICU

Antidepressant Use During Hospice Patients' Final Months on Routine Home Care

Background: Antidepressants can be used to manage symptoms at the end of life, but the dying process can impact their use. Objectives: To examine the use of antidepressants during hospice patients' final months of home care. Methods: A retrospective case records review of 227 hospice patients in their last three months of care in a residential setting. Chart reviews were conducted of medication logs, hospice staff notes, and caregiver narratives to examine antidepressant use including types of medications prescribed and factors associated with medication maintenance. Results: Thirty percent of patients were prescribed at least 1 antidepressant for symptoms including depression, anxiety, pain, disturbances in sleep, and poor appetite. The majority (96.1%) of patients were not administered their antidepressant on the day of death, and more than half (61.8%) did not receive their antidepressant during their last 3 days of life. A quarter (25.5%) of patients on antidepressants did not receive medication 4-7 days prior to death while some (12.7%) went without their antidepressant for 8 or more days. Antidepressant use was discontinued by hospice staff or caregivers due to a variety of reasons including difficulty swallowing, minimal consciousness, confusion, nausea, or patient refusal. Conclusions: Antidepressants are prescribed to manage multiple symptoms at the end of life, but use is often disrupted during patients' final days. Tapering and other prescription adjustments may be warranted to avoid risk of antidepressant discontinuation syndrome (ADS).

Impact of Abrupt Interruption of Home Psychotropic Medications at ICU Admission

Background: Abrupt discontinuation of home psychotropic medications is common among critically ill patients but may precipitate clinically significant withdrawal. Objective: To determine the percent of patients with interruptions in home psychotropic medications upon intensive care unit (ICU) admission and to identify outcomes associated with these interruptions. Methods: This was an institutional review board-approved, single-center, retrospective study of critically ill patients with a history of mental illness taking an antipsychotic or antidepressant medication. The primary outcome was the percent of patients with interruption in at least one home psychotropic medication for ≥24 hours upon ICU admission. Secondary outcomes included time to psychotropic re-initiation, percent of home psychotropic medications restarted in the ICU, ICU length of stay (LOS), delirium, withdrawal-related complications, need for acute antipsychotics or benzodiazepines, and reasons for psychotropic interruption. Results: Among 183 patients, 93 (50.8%) had interruptions in home psychotropic therapy for ≥24 hours upon ICU admission. Mean time to reinitiation of at least one psychotropic agent was 1.4 days, and 16.4% of patients did not have any home psychotropics restarted. Patients with psychotropic interruption had a longer ICU LOS (P = 0.01) and greater incidence of ICU delirium (P < 0.01). Withdrawal-related complications were similar between groups. Acute antipsychotic use was greater in patients with psychotropic interruption (P < 0.01). Acute benzodiazepine use was not different between groups (P = 0.87). Most patients did not have a documented reason for therapy interruption. Conclusion and Relevance: Unless contraindicated, clinicians should attempt to restart home psychotropic medications as soon as possible in critically ill patients.

Delirium in Intensive Care Units: Perceptions of Physicians and Nurses

Delirium is an indicator of morbidity and mortality in intensive care unit (ICU) patients. It can lead to negative outcomes and longer hospital stays, thus increasing hospital costs. Despite national recommendations for daily assessment of delirium, it remains underdiagnosed. Many studies point to a lack of knowledge among health care professionals to accurately detect and manage ICU delirium. The aim of our study was to assess the knowledge, attitudes, and practices of Palestinian health care professionals regarding ICU delirium. The results of a cross-section observational study revealed that delirium appears to be often underrecognized or misdiagnosed in ICUs in Palestine. Therefore, it is critical to further educate the medical and nursing teams and to promote the use of validated tools that can aid in the assessment of this condition. In this way, the length of hospital stays and related health care costs can be reduced.