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Shin HW, Kwak JS, Choi YJ, Kim JW, You HS, Shin HJ, Jang YK. Efficacy and safety of perioperative melatonin for postoperative delirium in patients undergoing surgery: a systematic review and meta-analysis. J Int Med Res 2024; 52:3000605241239854. [PMID: 38735057 PMCID: PMC11089947 DOI: 10.1177/03000605241239854] [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: 11/13/2023] [Accepted: 02/29/2024] [Indexed: 05/14/2024] Open
Abstract
OBJECTIVE To assess the efficacy and safety of perioperative melatonin and melatonin agonists in preventing postoperative delirium (POD). METHODS We conducted a systematic search for randomized controlled trials (RCTs) published through December 2022. The primary outcome was efficacy based on the incidence of POD (POD-I). Secondary outcomes included efficacy and safety according to the length of hospital or intensive care unit stay, in-hospital mortality, and adverse events. Subgroup analyses of POD-I were based on the type and dose of drug (low- and high-dose melatonin, ramelteon), the postoperative period (early or late), and the type of surgery. RESULTS In the analysis (16 RCTs, 1981 patients), POD-I was lower in the treatment group than in the control group (risk ratio [RR] = 0.57). POD-I was lower in the high-dose melatonin group than in the control group (RR = 0.41), whereas no benefit was observed in the low-dose melatonin and ramelteon groups. POD-I was lower in the melatonin group in the early postoperative period (RR = 0.35) and in patients undergoing cardiopulmonary surgery (RR = 0.54). CONCLUSION Perioperative melatonin or melatonin agonist treatment suppressed POD without severe adverse events, particularly at higher doses, during the early postoperative period, and after cardiopulmonary surgery.
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Affiliation(s)
- Hye Won Shin
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Ji Su Kwak
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Yoon Ji Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Ansan Hospital, Gyeonggi-do Province, Republic of Korea
| | - Jae Woo Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Hae Sun You
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Hyun Ju Shin
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Yoo Kyung Jang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
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Marsh J, Alexander E. Update on the Prevention and Treatment of Intensive Care Unit Delirium. AACN Adv Crit Care 2021; 32:5-10. [PMID: 33725100 DOI: 10.4037/aacnacc2021494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Jennifer Marsh
- Jennifer Marsh is a Critical Care Pharmacist, Department of Pharmacy Services, Tampa General Hospital, 1 Tampa General Circle, Tampa, FL 33601
| | - Earnest Alexander
- Earnest Alexander is Assistant Director, Clinical Pharmacy Services, Department of Pharmacy Services, Tampa General Hospital, Tampa, Florida
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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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Sanchez DL, Fusick AJ, Hudson WB, Schmitz JE, Catalano MC, Catalano G. Ramelteon in the Treatment of Delirium: New Perspectives from Reported Findings and a Case Observation. CURRENT DRUG THERAPY 2019. [DOI: 10.2174/1574885514666190308161421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
:
Ramelteon is a melatonin receptor agonist that is approved for the treatment of
insomnia. It is widely used due to its relatively benign side effect profile and lack of dependence
or withdrawal. Due to its tolerability, clinicians have attempted to utilize ramelteon
to normalize the sleep/wake patterns in patients with delirium as a safer alternative
to antipsychotics or other medications. We present the case of a 75-year-old man with
long-standing dementia who was hospitalized due to mental status changes, agitation, and
sleep disturbance. After addressing possible underlying causes with minimal improvement,
the team initiated treatment with ramelteon (8mg nightly) which resulted in rapid
improvement of symptoms. Uses and mechanisms of action of ramelteon will be reviewed,
as well as current pharmacologic treatments of delirium. Prior research studies
and case reports regarding the use of ramelteon in the treatment of delirium will be discussed
and suggestions made regarding possible areas of future study.
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Affiliation(s)
- Deborah L. Sanchez
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans Hospital, Tampa, Florida, United States
| | - Adam J. Fusick
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida Morsani College of Medicine, Tampa, Florida, United States
| | - William B. Hudson
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida Morsani College of Medicine, Tampa, Florida, United States
| | - Jourdan E. Schmitz
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Maria C. Catalano
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida Morsani College of Medicine, Tampa, Florida, United States
| | - Glenn Catalano
- Mental Health and Behavioral Sciences Service, James A. Haley Veterans Hospital, Tampa, Florida, United States
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Effect of Administration of Ramelteon, a Melatonin Receptor Agonist, on the Duration of Stay in the ICU: A Single-Center Randomized Placebo-Controlled Trial. Crit Care Med 2019; 46:1099-1105. [PMID: 29595562 PMCID: PMC6012040 DOI: 10.1097/ccm.0000000000003132] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Supplemental Digital Content is available in the text. Objectives: Occurrence of delirium in the ICU is associated with a longer stay in the ICU. To examine whether the use of ramelteon, a melatonin agonist, can prevent delirium and shorten the duration of ICU stay of critically ill patients. Design: A single-center, triple-blinded, randomized placebo-controlled trial. Setting: ICU of an academic hospital. Patients: Eligible patients were ICU patients who could take medicines orally or through a nasogastric tube during the first 48 hours of admission. Interventions: The intervention group received ramelteon (8 mg/d), and the control group received placebo (1 g/d of lactose powder) at 20:00 hours every day until discharge from the ICU. Measurements and Main Results: A total of 88 subjects were randomized to the ramelteon group (45 subjects) or the placebo group (43 subjects). As the primary endpoint, there was a trend toward decrease in the duration of ICU stay (4.56 d) in the ramelteon group compared with the placebo group (5.86 d) (p = 0.082 and p = 0.028 before and after adjustments). As the secondary endpoints, statistically significant decreases in the occurrence rate (24.4% vs 46.5%; p = 0.044) and duration (0.78 vs 1.40 d; p = 0.048) of delirium were observed in the ramelteon group. The nonintubated patients of the ramelteon group showed statistically significantly fewer awakenings per night and a higher proportion of nights without awakenings. Conclusions: Ramelteon tended to decrease the duration of ICU stay as well as decreased the occurrence rate and duration of delirium statistically significantly.
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Cascella M, Fiore M, Leone S, Carbone D, Di Napoli R. Current controversies and future perspectives on treatment of intensive care unit delirium in adults. World J Crit Care Med 2019; 8:18-27. [PMID: 31240172 PMCID: PMC6582227 DOI: 10.5492/wjccm.v8.i3.18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/19/2019] [Accepted: 05/05/2019] [Indexed: 02/06/2023] Open
Abstract
Delirium is the most frequent manifestation of acute brain dysfunction in intensive care unit (ICU). Although antipsychotics are widely used to treat this serious complication, recent evidence has emphasized that these agents did not reduce ICU delirium (ICU-D) prevalence and did not improve survival, length of ICU or hospital stay after its occurrence. Of note, no pharmacological strategy to prevent or treat delirium has been identified, so far. In this scenario, new scientific evidences are urgently needed. Investigations on specific ICU-D subgroups, or focused on different clinical settings, and studies on medications other than antipsychotics, such as dexmedetomidine or melatonin, may represent interesting fields of research. In the meantime, because there is some evidence that ICU-D can be effectively prevented, the literature suggests strengthening all the strategies aimed at prevention through no-pharmacological approaches mostly focused on the correction of risk factors. The more appropriate strategy useful to treat established delirium remains the use of antipsychotics managed by choosing the right doses after a careful case-by-case analysis. While the evidence regarding the use of dexmedetomidine is still conflicting and sparse, this drug offers interesting perspectives for both ICU-D prevention and treatment. This paper aims to provide an overview of current pharmacological approaches of evidence-based medicine practice. The state of the art of the on-going clinical research on the topic and perspectives for future research are also addressed.
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Affiliation(s)
- Marco Cascella
- Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, Naples 80049, Italy
| | - Marco Fiore
- Department of Women, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, Naples 80138, Italy
| | - Sebastiano Leone
- Division of Infectious Diseases, “San Giuseppe Moscati” Hospital, Avellino 83100, Italy
| | - Domenico Carbone
- Department of Emergency Medicine, Umberto I Hospital, Nocera Inferiore, Salerno 84014, Italy
| | - Raffaela Di Napoli
- Department of Anesthesiology, Institut Jules Bordet, Université Libre de Bruxelles, Bruxelles 1000, Belgium
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Zhang Q, Gao F, Zhang S, Sun W, Li Z. Prophylactic use of exogenous melatonin and melatonin receptor agonists to improve sleep and delirium in the intensive care units: a systematic review and meta-analysis of randomized controlled trials. Sleep Breath 2019; 23:1059-1070. [DOI: 10.1007/s11325-019-01831-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 02/21/2019] [Accepted: 03/21/2019] [Indexed: 12/29/2022]
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Choy SW, Yeoh AC, Lee ZZ, Srikanth V, Moran C. Melatonin and the Prevention and Management of Delirium: A Scoping Study. Front Med (Lausanne) 2018; 4:242. [PMID: 29376051 PMCID: PMC5767075 DOI: 10.3389/fmed.2017.00242] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 12/14/2017] [Indexed: 12/11/2022] Open
Abstract
Background The therapeutic benefit of melatonin in the prevention and treatment of delirium is uncertain. Objective To perform a scoping study to describe the existing literature regarding the use of melatonin and ramelteon in the prevention and treatment of delirium. Methods We performed a scoping study using the Arksey and O’Malley framework to explore our objective. Two independent panels searched MEDLINE, OVID, EMBASE, PubMed, Google Scholar, and Cochrane Library for relevant articles up to November 2017 describing the use of melatonin and ramelteon in the prevention or management of delirium. We extracted relevant summary data from the studies and attempted to draw conclusion regarding benefit. Results We summarized evidence from 20 relevant articles. There were a total of nine articles: five randomized controlled trials (RCTs), two retrospective medical record reviews, one non-randomized observational study, and one case report describing the role of either melatonin or ramelteon in preventing delirium. There were a total of 11 studies studying the role of either melatonin or ramelteon in the management of established delirium. None of these were RCT and were predominantly case series and case reports. Four of the five trials studying the effect of melatonin analogs in preventing delirium reported a beneficial effect but study heterogeneity limited any broad recommendations. Similarly, the lack of any well-designed trials limits any recommendations regarding the effect of melatonin analogs in treating delirium. Conclusion Large, well-designed clinical trials are required to explore the potential beneficial effects of melatonin and ramelteon on delirium prevention and management.
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Affiliation(s)
- Sin Wei Choy
- Department of Aged Care, Alfred Health, Melbourne, VIC, Australia.,Department of Geriatric Medicine, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Aun Chian Yeoh
- Department of Medicine, Peninsula Health, Frankston, VIC, Australia.,Peninsula Clinical School, Central Clinical School, Monash University, Frankston, VIC, Australia
| | - Zhao Zheng Lee
- Department of Medicine, Peninsula Health, Frankston, VIC, Australia.,Peninsula Clinical School, Central Clinical School, Monash University, Frankston, VIC, Australia
| | - Velandai Srikanth
- Department of Medicine, Peninsula Health, Frankston, VIC, Australia.,Peninsula Clinical School, Central Clinical School, Monash University, Frankston, VIC, Australia
| | - Chris Moran
- Department of Aged Care, Alfred Health, Melbourne, VIC, Australia.,Department of Medicine, Peninsula Health, Frankston, VIC, Australia.,Peninsula Clinical School, Central Clinical School, Monash University, Frankston, VIC, Australia
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