Impact of quetiapine on resolution of individual delirium symptoms in critically ill patients with delirium: a post-hoc analysis of a double-blind, randomized, placebo-controlled 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.

A National Modified Delphi Consensus Process to Prioritize Experiences and Interventions for Antipsychotic Medication Deprescribing Among Adult Patients With Critical Illness

Antipsychotic medications are frequently prescribed to critically ill patients leading to their continuation at transitions of care thereafter. The aim of this study was to generate evidence-informed consensus statements with key stakeholders on antipsychotic minimization and deprescribing for ICU patients.

DESIGN

We completed three rounds of surveys in a National modified Delphi consensus process. During rounds 1 and 2, participants used a 9-point Likert scale (1-strongly disagree, 9-strongly agree) to rate perceptions related to antipsychotic prescribing (i.e., experiences regarding delivery of patient care), knowledge and frequency of antipsychotic use, knowledge surrounding antipsychotic guideline recommendations, and strategies (i.e., interventions addressing current antipsychotic prescribing practices) for antipsychotic minimization and deprescribing. Consensus was defined as a median score of 1-3 or 7-9. During round 3, participants ranked statements on antipsychotic minimization and deprescribing strategies that achieved consensus (median score 7-9) using a weighted ranking scale (0-100 points) to determine priority.

SETTING

Online surveys distributed across Canada.

SUBJECTS

Fifty-seven stakeholders (physicians, nurses, pharmacists) who work with ICU patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Participants prioritized six consensus statements on strategies for consideration when developing and implementing interventions to guide antipsychotic minimization and deprescribing. Statements focused on limiting antipsychotic prescribing to patients: 1) with hyperactive delirium, 2) at risk to themselves, their family, and/or staff due to agitation, and 3) whose care and treatment are being impacted due to agitation or delirium, and prioritizing 4) communication among staff about antipsychotic effectiveness, 5) direct and efficient communication tools on antipsychotic deprescribing at transitions of care, and 6) medication reconciliation at transitions of care.

CONCLUSIONS

We engaged diverse stakeholders to generate evidence-informed consensus statements regarding antipsychotic prescribing perceptions and practices that can be used to implement interventions to promote antipsychotic minimization and deprescribing strategies for ICU patients with and following critical illness.

Pharmacologic treatment of delirium symptoms: A systematic review

OBJECTIVE

We conducted an updated, comprehensive, and contemporary systematic review to examine the efficacy of existing pharmacologic agents employed for management of delirium symptoms among hospitalized adults.

METHODS

Searches of PubMed, Scopus, Embase, and Cochrane Library databases from inception to May 2021 were performed to identify studies investigating efficacy of pharmacologic agents for management of delirium.

RESULTS

Of 11,424 articles obtained from searches, a total of 33 articles (N = 3030 participants) of randomized or non-randomized trials, in which pharmacologic treatment was compared to active comparator, placebo, or no treatment, met all criteria and were included in this review. Medications used for management of delirium symptoms included antipsychotic medications (N = 27), alpha-2 agonists (N = 5), benzodiazepines (N = 2), antidepressants (n = 1), acetylcholinesterase inhibitors (N = 2), melatonin (N = 2), opioids (N = 1), and antiemetics (N = 2). Despite somewhat mixed findings and a relative lack of high-quality trials, it appears that antipsychotic medications (e.g., haloperidol, olanzapine, risperidone, or quetiapine) and dexmedetomidine have the potential to improve delirium outcomes.

CONCLUSIONS

Pharmacologic agents can reduce delirium symptoms (e.g., agitation) in some hospitalized patients. Additional double-blinded, randomized, placebo-controlled clinical trials are critically needed to investigate the efficacy of pharmacologic agents for diverse hospitalized populations (e.g., post-surgical patients, patients at the end-of-life, or in intensive care units).

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Discharge from hospital with newly administered antipsychotics after intensive care unit delirium - Incidence and contributing factors

PURPOSE

Delirium in the intensive care unit (ICU) is often treated with haloperidol or atypical antipsychotics. Antipsychotic treatment can lead to severe adverse effects and excess mortality. After initiation in the ICU, patients are at risk of having their antipsychotics continued unnecessarily at ICU and hospital discharge. This study aims to determine the incidence of, and risk factors for antipsychotic continuation at hospital discharge after ICU delirium.

METHODS

This retrospective observational study was performed in a tertiary care center. Adult patients who received antipsychotics for ICU delirium during 2016 were included. Data was extracted from patient records. After univariate testing, a multivariate binary logistic regression model was used to identify independent risk factors for antipsychotic continuation.

RESULTS

A total of 196 patients were included, of which 104 (53.1%) and 41 (20.9%) had their antipsychotics continued at ICU and hospital discharge respectively. Medical ICU admission (odds ratio [95% confidence interval] 2.97 [1.37-6.41]) and quetiapine treatment (5.81 [1.63-20.83]) were independently associated with antipsychotic continuation at hospital discharge.

CONCLUSIONS

Approximately one in five patients were discharged from the hospital with continued antipsychotics. Hospital policies should implement strategies for systematic antipsychotic tapering and better follow-up of antipsychotics at transitions of care.

Efficacy of Low-Dose Prophylactic Quetiapine on Delirium Prevention in Critically Ill Patients: A Prospective, Randomized, Double-Blind, Placebo-Controlled Study

Purpose: To evaluate the efficacy of short-term low-dose quetiapine for delirium prevention in critically ill patients. Methods: In this prospective, a single-center, randomized, double-blind, placebo-controlled trial, adult patients who were admitted from July 2015 to July 2017 to a medical intensive care unit (ICU) of a tertiary teaching hospital affiliated to Seoul National University were included. Quetiapine (12.5 mg or 25 mg oral at night; N = 16) or placebo (N = 21) was administered according to randomization until ICU discharge or the 10th ICU day. The primary endpoint was the incidence of delirium within the first 10 ICU days. Secondary endpoints included the rate of positive Confusion Assessment Method for the ICU (CAM-ICU) (the number of positive CAM-ICU counts/the number of total CAM-ICU counts), delirium duration, successful extubation, and overall mortality. Result: The incidence of delirium during the 10 days after ICU admission was 46.7% (7/15) in the quetiapine group and 55.0% (11/20) in the placebo group (p = 0.442). In the quetiapine group, the rate of positive CAM-ICU was significantly lower than in the placebo group (14.4% vs. 37.4%, p = 0.048), delirium duration during the study period was significantly shorter (0.28 day vs. 1.83 days, p = 0.018), and more patients in the quetiapine than in the placebo group were weaned from mechanical ventilation successfully (84.6% vs. 47.1%, p = 0.040). Conclusions: Our study suggests that prophylactic use of low-dose quetiapine could be helpful for preventing delirium in critically ill patients. A further large-scale prospective study is needed.

Pharmacological interventions for the treatment of delirium in critically ill adults

BACKGROUND

Although delirium is typically an acute reversible cognitive impairment, its presence is associated with devastating impact on both short-term and long-term outcomes for critically ill patients. Advances in our understanding of the negative impact of delirium on patient outcomes have prompted trials evaluating multiple pharmacological interventions. However, considerable uncertainty surrounds the relative benefits and safety of available pharmacological interventions for this population.

OBJECTIVES

Primary objective1. To assess the effects of pharmacological interventions for treatment of delirium on duration of delirium in critically ill adults with confirmed or documented high risk of deliriumSecondary objectivesTo assess the following:1. effects of pharmacological interventions on delirium-free and coma-free days; days with coma; delirium relapse; duration of mechanical ventilation; intensive care unit (ICU) and hospital length of stay; mortality; and long-term outcomes (e.g. cognitive; discharge disposition; health-related quality of life); and2. the safety of such treatments for critically ill adult patients.

SEARCH METHODS

We searched the following databases from their inception date to 21 March 2019: Ovid MEDLINE®, Ovid MEDLINE® In-Process & Other Non-Indexed Citations, Embase Classic+Embase, and PsycINFO using the Ovid platform. We also searched the Cochrane Library on Wiley, the International Prospective Register of Systematic Reviews (PROSPERO) (http://www.crd.york.ac.uk/PROSPERO/), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science. We performed a grey literature search of relevant databases and websites using the resources listed in Grey Matters developed by the Canadian Agency for Drugs and Technologies in Health (CADTH). We also searched trial registries and abstracts from annual scientific critical care and delirium society meetings.

SELECTION CRITERIA

We sought randomized controlled trials (RCTs), including quasi-RCTs, of any pharmacological (drug) for treatment of delirium in critically ill adults. The drug intervention was to be compared to another active drug treatment, placebo, or a non-pharmacological intervention (e.g. mobilization). We did not apply any restrictions in terms of drug class, dose, route of administration, or duration of delirium or drug exposure. We defined critically ill patients as those treated in an ICU of any specialty (e.g. burn, cardiac, medical, surgical, trauma) or high-dependency unit.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified studies from the search results; four review authors (in pairs) performed data extraction and assessed risk of bias independently. We performed data synthesis through pairwise meta-analysis and network meta-analysis (NMA). Our hypothetical network structure was designed to be analysed at the drug class level and illustrated a network diagram of 'nodes' (i.e. drug classes) and 'edges' (i.e. comparisons between different drug classes from existing trials), thus describing a treatment network of all possible comparisons between drug classes. We assessed the quality of the body of evidence according to GRADE, as very low, low, moderate, or high.

MAIN RESULTS

We screened 7674 citations, from which 14 trials with 1844 participants met our inclusion criteria. Ten RCTs were placebo-controlled, and four reported comparisons of different drugs. Drugs examined in these trials were the following: antipsychotics (n = 10), alpha2 agonists (n = 3; all dexmedetomidine), statins (n = 2), opioids (n = 1; morphine), serotonin antagonists (n = 1; ondansetron), and cholinesterase (CHE) inhibitors (n = 1; rivastigmine). Only one of these trials consistently used non-pharmacological interventions that are known to improve patient outcomes in both intervention and control groups.Eleven studies (n = 1153 participants) contributed to analysis of the primary outcome. Results of the NMA showed that the intervention with the smallest ratio of means (RoM) (i.e. most preferred) compared with placebo was the alpha2 agonist dexmedetomidine (0.58; 95% credible interval (CrI) 0.26 to 1.27; surface under the cumulative ranking curve (SUCRA) 0.895; moderate-quality evidence). In order of descending SUCRA values (best to worst), the next best interventions were atypical antipsychotics (RoM 0.80, 95% CrI 0.50 to 1.11; SUCRA 0.738; moderate-quality evidence), opioids (RoM 0.88, 95% CrI 0.37 to 2.01; SUCRA 0.578; very-low quality evidence), and typical antipsychotics (RoM 0.96, 95% CrI 0.64 to1.36; SUCRA 0.468; high-quality evidence).The NMAs of multiple secondary outcomes revealed that only the alpha2 agonist dexmedetomidine was associated with a shorter duration of mechanical ventilation (RoM 0.55, 95% CrI 0.34 to 0.89; moderate-quality evidence), and the CHE inhibitor rivastigmine was associated with a longer ICU stay (RoM 2.19, 95% CrI 1.47 to 3.27; moderate-quality evidence). Adverse events often were not reported in these trials or, when reported, were rare; pair-wise analysis of QTc prolongation in seven studies did not show significant differences between antipsychotics, ondansetron, dexmedetomidine, and placebo.

AUTHORS' CONCLUSIONS

We identified trials of varying quality that examined six different drug classes for treatment of delirium in critically ill adults. We found evidence that the alpha2 agonist dexmedetomidine may shorten delirium duration, although this small effect (compared with placebo) was seen in pairwise analyses based on a single study and was not seen in the NMA results. Alpha2 agonists also ranked best for duration of mechanical ventilation and length of ICU stay, whereas the CHE inhibitor rivastigmine was associated with longer ICU stay. We found no evidence of a difference between placebo and any drug in terms of delirium-free and coma-free days, days with coma, physical restraint use, length of stay, long-term cognitive outcomes, or mortality. No studies reported delirium relapse, resolution of symptoms, or quality of life. The ten ongoing studies and the six studies awaiting classification that we identified, once published and assessed, may alter the conclusions of the review.

In a Model of Neuroinflammation Designed to Mimic Delirium, Quetiapine Reduces Cortisol Secretion and Preserves Reversal Learning in the Attentional Set Shifting Task

Quetiapine, an atypical antipsychotic medication has lacked pre-clinical validation for its purported benefits in the treatment of delirium. This laboratory investigation examined the effects of quetiapine on the attentional set shifting task (ASST), a measure of cognitive flexibility and executive functioning, in a rodent model of lipopolysaccharide (LPS) mediated neuroinflammation. 19 Sprague Dawley female rats were randomly selected to receive intraperitoneal placebo (N = 5), LPS and placebo (N = 7) or LPS and quetiapine (n = 7) and performed the ASST. We measured trials to criterion, errors, non-locomotion episodes and latency to criterion, serum cortisol and tumor necrosis factor alpha (TNF-α) levels. TNF-α levels were not different between groups at 24 h. Cortisol levels in the LPS + Quetiapine group were reduced compared to LPS + Placebo (P < 0.001) and did not differ from the placebo group (P = 0.15). Analysis between LPS + Quetiapine and LPS + Placebo treated rats demonstrated improvement in the compound discrimination reversal (CD Rev1) (P = 0.016) and the intra-dimensional reversal (ID Rev2) (P = 0.007) discriminations on trials to criterion. LPS + Quetiapine treated rats had fewer errors than LPS + Placebo treated animals in the compound discrimination (CD) (P = 0.007), CD Rev1 (P = 0.005), ID Rev2 (P < 0.001) discriminations. There was no difference in non-locomotion frequency or latency to criterion between the three groups in all discriminations (P > 0.0167). We demonstrated preserved reversal learning, no effect on attentional set shifting and normalized cortisol levels in quetiapine-treated rats in this neuroinflammatory model of delirium. This suggests that quetiapine's beneficial effects in delirium may be related to the preservation of reversal learning and potential downstream effects related to reduction in cortisol production. Graphical Abstract.

Pediatric Delirium in the Cardiac Intensive Care Unit: Identification and Intervention

Delirium is characterized by transient behavioral manifestations of acute brain disturbances. Delirium in the intensive care unit has been well researched and documented in the adult population. Pediatric delirium research has lagged, but recent developments in screening tools have shed light on the prevalence of delirium among children. The overall prevalence of delirium in the pediatric intensive care unit is 25%. A recent study showed a prevalence of 49% in the pediatric cardiac intensive care unit; this higher prevalence may be due to factors related to critical illness and the postoperative environment. This article is intended to increase awareness of delirium in the pediatric cardiac intensive care unit and give nurses the tools to identify it and intervene when necessary. A definition of delirium is provided, and its prevalence, risk factors, and current knowledge are reviewed. Available screening tools and environmental and pharmacological interventions are explored.

Pharmacologic Treatment of Intensive Care Unit Delirium and the Impact on Duration of Delirium, Length of Intensive Care Unit Stay, Length of Hospitalization, and 28-Day Mortality

OBJECTIVE

To determine whether treatment of delirium affects outcomes.

PATIENTS AND METHODS

A retrospective cohort study of patients admitted to the medical intensive care unit (ICU) from July 1, 2015, through June 30, 2016, was conducted. Patients with ICU delirium, defined by a positive Confusion Assessment Method for the ICU score, were included. Patients were stratified into 4 treatment groups based on exposure to melatonin and antipsychotic agents during ICU stay: no pharmacologic treatment, melatonin only, antipsychotics only, and both melatonin and antipsychotics. A time-dependent cause-specific hazards model with death as a competing risk was used to evaluate the effect of melatonin or antipsychotic drug use for delirium on duration of ICU delirium, length of ICU stay, and length of hospitalization. A logistic regression was used to evaluate 28-day mortality. Covariates significantly associated with exposure to melatonin and antipsychotics were included in the minimally adjusted model. Covariates significantly associated in the minimally adjusted model were included in a final adjusted model.

RESULTS

A total of 449 admissions to the medical ICU were included in the analysis. Exposure to melatonin or antipsychotic agents did not reduce the duration of ICU delirium, ICU/hospital length of stay, or 28-day mortality. However, antipsychotic use only was associated with longer hospitalization.

CONCLUSION

Antipsychotic drugs for the treatment ICU delirium may not provide the benefit documented in earlier literature. Further investigation on patient selection, type of antipsychotic, and dosing is needed.

Pharmacologic Management of Delirium in the ICU: A Review of the Literature

Purpose:

Conflicting data exists on the pharmacologic management of intensive care unit (ICU) delirium. This review appraises the current evidence of pharmacologic management of ICU delirium.

Materials and Methods:

A systematic literature search of MEDLINE and Embase was conducted to answer the population, intervention, comparison, and outcome (PICO) question of: “Does the use of a pharmacologic agent compared to standard of care or placebo improve ICU delirium in a critically ill patient population?”

Results:

After application of the PICO question and the inclusion and exclusion criteria, 13 articles were included. Of these articles, 7 were prospective randomized controlled trials, 1 was a prospective nonrandomized controlled trial, and 5 were retrospective investigations. The included articles differed in the agents evaluated, primary outcome, and method of identifying delirium.

Conclusion:

The variability of outcomes illustrates the need for a large-scale investigation to further evaluate the role of pharmacologic management of ICU delirium.

Ramelteon is Not Associated With Improved Outcomes Among Critically Ill Delirious Patients: A Single-Center Retrospective Cohort Study

BACKGROUND

Delirium commonly affects critically ill patients and is associated with high morbidity and mortality. Some studies have suggested that ramelteon may prevent delirium, but ramelteon's impact on treating delirium is unknown.

OBJECTIVE

To compare outcomes of critically ill delirious patients treated with ramelteon versus those who were not.

METHODS

Retrospective cohort study of 322 intensive care unit patients stratified based on ramelteon exposure after a nonnegative Confusion Assessment Method-ICU score.

MAIN OUTCOMES

Primary outcomes were hours alive without delirium or coma and likelihood of delirium-coma resolution. Secondary outcomes were ventilator-free hours, likelihood of extubation, and mortality.

RESULTS

Hazard ratios for delirium-coma resolution, extubation, and 10-day mortality were 1.05 (95% confidence interval 0.54-2.01), 1.20 (95% confidence interval 0.47-3.03), and 0.31 (95% confidence interval 0.07-1.32), respectively. Median delirium-coma free hours did not differ between ramelteon exposed and unexposed patients. Median ventilator-free hours were higher in the ramelteon group, however, ramelteon was administered postextubation in 92% of cases.

CONCLUSIONS

Ramelteon was not associated with increased likelihood of delirium-coma resolution, extubation, or changes in mortality.

Antipsychotics for treatment of delirium in hospitalised non-ICU patients

BACKGROUND

Guidelines suggest limited and cautious use of antipsychotics for treatment of delirium where nonpharmacological interventions have failed and symptoms remain distressing or dangerous, or both. It is unclear how well these recommendations are supported by current evidence.

OBJECTIVES

Our primary objective was to assess the efficacy of antipsychotics versus nonantipsychotics or placebo on the duration of delirium in hospitalised adults. Our secondary objectives were to compare the efficacy of: 1) antipsychotics versus nonantipsychotics or placebo on delirium severity and resolution, mortality, hospital length of stay, discharge disposition, health-related quality of life, and adverse effects; and 2) atypical vs. typical antipsychotics for reducing delirium duration, severity, and resolution, hospital mortality and length of stay, discharge disposition, health-related quality of life, and adverse effects.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane EBM Reviews, CINAHL, Thomson Reuters Web of Science and the Latin American and Caribbean Health Sciences Literature (LILACS) from their respective inception dates until July 2017. We also searched the Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database, Web of Science ISI Proceedings, and other grey literature.

SELECTION CRITERIA

We included randomised and quasi-randomised trials comparing 1) antipsychotics to nonantipsychotics or placebo and 2) typical to atypical antipsychotics for the treatment of delirium in adult hospitalised (but not critically ill) patients.

DATA COLLECTION AND ANALYSIS

We examined titles and abstracts of identified studies to determine eligibility. We extracted data independently in duplicate. Disagreements were settled by further discussion and consensus. We used risk ratios (RR) with 95% confidence intervals (CI) as a measure of treatment effect for dichotomous outcomes, and between-group standardised mean differences (SMD) with 95% CI for continuous outcomes.

MAIN RESULTS

We included nine trials that recruited 727 participants. Four of the nine trials included a comparison of an antipsychotic to a nonantipsychotic drug or placebo and seven included a comparison of a typical to an atypical antipsychotic. The study populations included hospitalised medical, surgical, and palliative patients.No trial reported on duration of delirium. Antipsychotic treatment did not reduce delirium severity compared to nonantipsychotic drugs (standard mean difference (SMD) -1.08, 95% CI -2.55 to 0.39; four studies; 494 participants; very low-quality evidence); nor was there a difference between typical and atypical antipsychotics (SMD -0.17, 95% CI -0.37 to 0.02; seven studies; 542 participants; low-quality evidence). There was no evidence antipsychotics resolved delirium symptoms compared to nonantipsychotic drug regimens (RR 0.95, 95% CI 0.30 to 2.98; three studies; 247 participants; very low-quality evidence); nor was there a difference between typical and atypical antipsychotics (RR 1.10, 95% CI 0.79 to 1.52; five studies; 349 participants; low-quality evidence). The pooled results indicated that antipsychotics did not alter mortality compared to nonantipsychotic regimens (RR 1.29, 95% CI 0.73 to 2.27; three studies; 319 participants; low-quality evidence) nor was there a difference between typical and atypical antipsychotics (RR 1.71, 95% CI 0.82 to 3.35; four studies; 342 participants; low-quality evidence).No trial reported on hospital length of stay, hospital discharge disposition, or health-related quality of life. Adverse event reporting was limited and measured with inconsistent methods; in those reporting events, the number of events were low. No trial reported on physical restraint use, long-term cognitive outcomes, cerebrovascular events, or QTc prolongation (i.e. increased time in the heart's electrical cycle). Only one trial reported on arrhythmias and seizures, with no difference between typical or atypical antipsychotics. We found antipsychotics did not have a higher risk of extrapyramidal symptoms (EPS) compared to nonantipsychotic drugs (RR 1.70, 95% CI 0.04 to 65.57; three studies; 247 participants; very-low quality evidence); pooled results showed no increased risk of EPS with typical antipsychotics compared to atypical antipsychotics (RR 12.16, 95% CI 0.55 to 269.52; two studies; 198 participants; very low-quality evidence).

AUTHORS' CONCLUSIONS

There were no reported data to determine whether antipsychotics altered the duration of delirium, length of hospital stay, discharge disposition, or health-related quality of life as studies did not report on these outcomes. From the poor quality data available, we found antipsychotics did not reduce delirium severity, resolve symptoms, or alter mortality. Adverse effects were poorly or rarely reported in the trials. Extrapyramidal symptoms were not more frequent with antipsychotics compared to nonantipsychotic drug regimens, and no different for typical compared to atypical antipsychotics.

Oral Agents for the Management of Agitation and Agitated Delirium in Critically Ill Patients

Agitation is one of the most common issues that critically ill patients experience. Medications used to manage agitation are often administered intravenously or intramuscularly in the acutely agitated, critically ill patient. However, a multimodal approach that utilizes multiple routes of administration may be appropriate. This review summarizes the available literature on oral antipsychotics, clonidine, and valproic acid to manage agitation in critically ill patients while also focusing on their pharmacology and appropriate monitoring. Despite inconclusive findings from different studies, antipsychotics, clonidine, and valproic acid may provide benefit for specific patient populations. As more evidence emerges, these agents may start playing a greater role in the management of agitation, which is not amenable to first-line agents. As health care professionals, it is prudent to be familiar with their dosing regimens, common adverse effects, and the monitoring required to maximize patient benefits and minimize harms.

Preventive strategies and potential therapeutic interventions for delirium in sepsis

Delirium is the most frequent and severe clinical presentation of brain dysfunction in critically ill septic patients with an incidence ranging from 9% to 71%. Delirium represents a significant burden for patients and relatives, as well as to the health care system, resulting in higher costs, long-term cognitive impairment and significant risk of death after 6 months. Current interventions for the prevention of delirium typically involve early recognition and amelioration of modifiable risk factors and treatment of underlying conditions that predisposes the individual to delirium. Several pharmacological interventions to prevent and treat delirium have been tested, although their effectiveness remains uncertain, especially in larger and more homogeneous subgroups of ICU patients, like in patients with sepsis. To date, there is inconsistent and conflicting data regarding the efficacy of any particular pharmacological agent, thus substantial attention has been paid to non-pharmacological interventions and preventive strategies should be applied to every patient admitted in the ICU. Future trials should be designed to evaluate the impact of these pharmacologic interventions on the prevention and treatment of delirium on clinically relevant outcomes such as length of stay, hospital mortality and long-term cognitive function. The role of specific medications like statins in delirium prevention is also yet to be evaluated.

Comparative effectiveness of quetiapine and haloperidol in delirium: A single blind randomized controlled study

AIM

To evaluate the effectiveness of quetiapine and haloperidol in patients of delirium referred to psychiatry consultation liaison services.

METHODS

The study followed a single blind randomised controlled trial design. Thirty-two patients in the haloperidol group and 31 patients in the quetiapine group were assessed at the baseline and 6 consecutive days. Flexible dosing regimen (haloperidol: 0.25-1.25 mg; quetiapine 12.5-75 mg/d) was used. Delirium Rating Scale-Revised-98 (DRS-R-98) and mini mental status examination (MMSE) were the primary and secondary efficacy measures respectively.

RESULTS

Baseline DRS-R-98 severity score and MMSE scores did not differ between the 2 study groups. From baseline to day 6, there was significant reduction in the total DRS-R-98 scores, DRS-R-98 cognitive domain scores, DRS-R-98 non-cognitive domain scores and significant increase in the MMSE scores in both the groups. Both the groups did not differ on any of the assessments in terms of DRS-R98 and MMSE scores. The effectiveness of both the medications was similar in adult and elderly (≥ 60 years) patients. At the end of the trial, 68.75% and 67.74% of subjects in the haloperidol and quetiapine group respectively had mean DRS-R-98 scores below 10. By 6^th day, 12 (37.5%) patients in haloperidol group and 9 (29.03%) patients in the quetiapine group had DRS-R98 score of “0” with no significant difference between the two groups (P = 0.47).

CONCLUSION

Quetiapine is as effective as haloperidol in the management of delirium.

Evaluation of Neuroleptic Utilization in the Intensive Care Unit During Transitions of Care

PURPOSE

The purpose of this study was to identify risk factors associated with inappropriate continuation of neuroleptics postdischarge from the intensive care unit (ICU) and hospital.

MATERIALS AND METHODS

A retrospective chart review was performed including all patients greater than 18 years of age who received neuroleptic medications in an ICU.

RESULTS

One hundred sixty-one patients were included during the 12- month study period. There were 85 (53%) patients discharged from the ICU with inappropriate continuation of a neuroleptic medication. There were 54 (34%) patients discharged from the hospital with inappropriate continuation of a neuroleptic medication. Patients were more likely to be discharged from the ICU with an inappropriate neuroleptic if they were prescribed multiple neuroleptics ( P = .02), did not have a urine drug screen collected at admission ( P = .023), or if trazodone was utilized in their therapy ( P = .004). Patients were more likely to be discharged from the hospital with a neuroleptic if they had multiple neuroleptic orders ( P = .0001) or if trazodone was utilized in their therapy ( P = .0023).

CONCLUSION

Risk factors associated with the continuation of inappropriate neuroleptic medications upon discharge from the ICU or the hospital include multiple neuroleptic medications prescribed, the lack of a urine drug screen upon admission, and the utilization of trazodone.

A Single-Dose Crossover Pharmacokinetic Comparison Study of Oral, Rectal and Topical Quetiapine in Healthy Adults

INTRODUCTION

Quetiapine is an oral atypical antipsychotic drug commonly used to treat a large number of neuropsychiatric disorders and conditions. However, a substantial number of patients who may benefit from treatment with quetiapine are unable to ingest quetiapine or other medications by mouth and thus require alternative routes of administration. There are currently no studies evaluating non-oral compounded dosage forms of quetiapine.

METHODS

We conducted a single-dose open-label crossover pharmacokinetic study in 10 healthy adults to determine whether quetiapine compounded as a rectal suppository or a topical cream achieved absorption similar to that achieved by a commercially available oral formulation.

RESULTS

Rectal quetiapine produced an area under the plasma concentration-time curve from time zero to infinity (AUC∞) approximately 90 % greater than that produced by an equal (milligram per milligram) dose of oral quetiapine (15,333 ng/mL versus 8118.8 ng/mL, p = 0.005). However, only two of ten subjects who received topical quetiapine had detectable serum levels. When detected, serum levels achieved with topical quetiapine were delayed and low in comparison with those produced by the oral and rectal dosage forms.

CONCLUSION

Our results suggest that rectal, but not topical, quetiapine may be useful in clinical settings. Clinical outcome studies of rectal quetiapine are needed.

Cognitive Dysfunction, Delirium, and Stroke in Cardiac Surgery Patients

Neurologic injury in the form of cognitive decline, delirium, and stroke are common phenomena in patients undergoing cardiac surgery and continues to be one of the most common complication after cardiac surgery, in spite of improvements in mortality and and improved surgical and anesthetic techniques. These complications lead to a significant increase in length of stay in the intensive care unit, increased length of hospital admission, and functional impairment, resulting in not only profound negative effects on patients who experience these complications, but also to increased costs of medical care and delivery. We discuss each of these complications in regard to their risks factors, incidence, potential therapeutic modalities, and relevant intraoperative and postoperative considerations.

Can intensive care unit delirium be prevented and reduced? Lessons learned and future directions

Delirium is a form of acute brain injury that occurs in up to 80% of critically ill patients. It is a source of enormous societal and financial burdens due to increased mortality, prolonged intensive care unit (ICU) and hospital stays, and long-term neuropsychological and functional deficits in ICU survivors. These poor outcomes are not only independently associated with the development of delirium but are also associated with increasing delirium duration. Therefore, interventions should strive both to prevent the occurrence of ICU delirium and to limit its persistence. Both patient-centered and ICU-acquired risk factors need to be addressed early in the ICU course to maximize the efficacy of prevention strategies and to improve long-term outcomes of ICU patients. In this article, we review strategies for early detection of patients who are delirious and who are at high risk for developing delirium, and we present a clinically useful ICU delirium prevention and reduction strategy for clinicians to incorporate into their daily practice.

Treating an established episode of delirium in palliative care: expert opinion and review of the current evidence base with recommendations for future development

CONTEXT

Delirium is a highly prevalent complication in patients in palliative care settings, especially in the end-of-life context.

OBJECTIVES

To review the current evidence base for treating episodes of delirium in palliative care settings and propose a framework for future development.

METHODS

We combined multidisciplinary input from delirium researchers and other purposely selected stakeholders at an international delirium study planning meeting. This was supplemented by a literature search of multiple databases and relevant reference lists to identify studies regarding therapeutic interventions for delirium.

RESULTS

The context of delirium management in palliative care is highly variable. The standard management of a delirium episode includes the investigation of precipitating and aggravating factors followed by symptomatic treatment with drug therapy. However, the intensity of this management depends on illness trajectory and goals of care in addition to the local availability of both investigative modalities and therapeutic interventions. Pharmacologically, haloperidol remains the practice standard by consensus for symptomatic control. Dosing schedules are derived from expert opinion and various clinical practice guidelines as evidence-based data from palliative care settings are limited. The commonly used pharmacologic interventions for delirium in this population warrant evaluation in clinical trials to examine dosing and titration regimens, different routes of administration, and safety and efficacy compared with placebo.

CONCLUSION

Delirium treatment is multidimensional and includes the identification of precipitating and aggravating factors. For symptomatic management, haloperidol remains the practice standard. Further high-quality collaborative research investigating the appropriate treatment of this complex syndrome is needed.

Intensive care unit delirium: a review of the literature

PURPOSE

The recent literature regarding intensive care unit (ICU) delirium and updated clinical practice guidelines are reviewed.

SUMMARY

Recent studies show that ICU delirium in critically ill patients is an independent predictor of higher mortality, longer ICU and hospital stay, and is associated with multiple clinical complications. Delirium has been reported to occur in greater than 80% of hospitalized critically ill patients, yet it remains an underdiagnosed condition. Several subtypes of delirium have been identified including hypoactive, hyperactive, and mixed presentation. Although the exact mechanism is unknown, several factors are thought to interact to cause delirium. Multiple risk factors related to medications, acute illness, the environment, and patient characteristics may contribute to the development of delirium. Practical bedside screening tools have been validated and are recommended to identify ICU patients with delirium. Nonpharmacologic interventions such as early mobilization have resulted in better functional outcomes, decreased incidence and duration of delirium, and more ventilator-free days. Data supporting pharmacologic treatments are limited.

CONCLUSION

Clinicians should become familiar with tools to identify delirium in order to initiate treatment and remove mitigating factors early in hospitalization to prevent delirium. Pharmacists are in a unique position to reduce delirium through minimization of medication-related risk factors and development of protocols.

What do we really know about the treatment of delirium with antipsychotics? Ten key issues for delirium pharmacotherapy

Despite the significant burden of delirium among hospitalized adults, no pharmacologic intervention is approved for delirium treatment. Antipsychotic agents are the best studied but there are uncertainties as to how these agents can be optimally applied in everyday practice. We searched Medline and PubMed databases for publications from 1980 to April 2012 to identify studies of delirium treatment with antipsychotic agents. Studies of primary prevention using pharmacotherapy were not included. We identified 28 prospective studies that met our inclusion criteria, of which 15 were comparison studies (11 randomized), 2 of which were placebo-controlled. The quality of comparison studies was assessed using the Jadad scale. The DRS (N = 12) and DRS-R98 (N = 9) were the most commonly used instruments for measuring responsiveness. These studies suggest that around 75% of delirious patients who receive short-term treatment with low-dose antipsychotics experience clinical response. Response rates appear quite consistent across different patient groups and treatment settings. Studies do not suggest significant differences in efficacy for haloperidol versus atypical agents, but report higher rates of extrapyramidal side effects with haloperidol. Comorbid dementia may be associated with reduced response rates but this requires further study. The available evidence does not indicate major differences in response rates between clinical subtypes of delirium. The extent to which therapeutic effects can be explained by alleviation of specific symptoms (e.g. sleep or behavioral disturbances) versus a syndromal effect that encompasses both cognitive and noncognitive symptoms of delirium is not known. Future research needs to explore the relationship between therapeutic effects and changes in pathophysiological markers of delirium. Less than half of reports were rated as reasonable quality evidence on the Jadad scale, highlighting the need for future studies of better quality design, and in particular incorporating placebo-controlled work.

Agitation during prolonged mechanical ventilation at a long-term acute care hospital: risk factors, treatments, and outcomes

INTRODUCTION

The prevalence, risk factors, treatment practices, and outcomes of agitation in patients undergoing prolonged mechanical ventilation (PMV) in the long-term acute care hospital (LTACH) setting are not well understood. We compared agitation risk factors, management strategies, and outcomes between patients who developed agitation and those who did not, in LTACH patients undergoing PMV.

METHODS

Patients admitted to an LTACH for PMV over a 1-year period were categorized into agitated and nonagitated groups. The presence of agitation risk factors, management strategies, and relevant outcomes were extracted and compared between the 2 groups.

RESULTS

A total of 80 patients were included, 41% (33) with agitation and 59% (47) without. Compared to the nonagitated group, the agitated group had a lower Sequential Organ Failure Assessment score (P < .0006), a greater transfer rate from an academic center (P = .05), a greater delirium frequency at both baseline (P = .04) and during admission (P < .001), and a greater rate of benzodiazepine discontinuation (P = .02). Although the use of scheduled antipsychotic (P = .0005) or restraint (P = .002) therapy was more common in the agitated group, use of benzodiazepines (P = .16), opioids (P = .11), or psychiatric evaluation (P = .90) was not. Weaning success, duration of LTACH stay, and daily costs were similar.

CONCLUSION

Agitation among the LTACH patients undergoing PMV is associated with greater delirium and use of antipsychotics and restraints but does not influence weaning success or LTACH stay. Strategies focused on agitation prevention and treatment in this population need to be developed and formally evaluated.

Quetiapine for the treatment of delirium

BACKGROUND

Delirium is associated with high rates of morbidity and mortality in hospitalized medically ill patients. Haloperidol has historically been the agent of choice for the treatment of delirium, but recent studies have explored the efficacy of second-generation antipsychotics such as quetiapine. The unique pharmacology of quetiapine may allow it to treat delirium and provide sedation without causing significant extrapyramidal side effects.

PURPOSE

To evaluate the efficacy of quetiapine for the treatment of delirium.

DATA SOURCES

A search was conducted in MEDLINE and Embase (January 1960-December 2012) using keywords "quetiapine," "second-generation antipsychotic," "atypical antipsychotic," "delirium," and "agitation."

STUDY SELECTION AND DATA EXTRACTION

The search was limited to English-language articles and trials with treatment of delirium as the primary end point. Eight trials met this inclusion criterion.

DATA SYNTHESIS

Two randomized controlled trials, 5 open-label studies, and 1 retrospective cohort study evaluating quetiapine for the treatment of delirium were reviewed. One randomized controlled trial showed no differences in total mean delirium scores, but found the rate of delirium improvement was significantly shorter with quetiapine. The second randomized controlled trial showed the time to first resolution of delirium was shorter with quetiapine compared to placebo. Results of the open-label and retrospective cohort trials have also shown significant resolution of delirium from baseline and equal efficacy with quetiapine compared to amisulpride and haloperidol.

CONCLUSIONS

Quetiapine appears to be an effective and safe agent for the treatment of delirium in both general medicine and intensive care unit patients. The trials summarized suggest that quetiapine resolves symptoms of delirium more quickly than placebo and has equal efficacy compared to haloperidol and the atypical antipsychotic amisulpride. Further study is needed.

Strategies for prevention of postoperative delirium: a systematic review and meta-analysis of randomized trials

INTRODUCTION

The ideal measures to prevent postoperative delirium remain unestablished. We conducted this systematic review and meta-analysis to clarify the significance of potential interventions.

METHODS

The PRISMA statement guidelines were followed. Two researchers searched MEDLINE, EMBASE, CINAHL and the Cochrane Library for articles published in English before August 2012. Additional sources included reference lists from reviews and related articles from 'Google Scholar'. Randomized clinical trials (RCTs) on interventions seeking to prevent postoperative delirium in adult patients were included. Data extraction and methodological quality assessment were performed using predefined data fields and scoring system. Meta-analysis was accomplished for studies that used similar strategies. The primary outcome measure was the incidence of postoperative delirium. We further tested whether interventions effective in preventing postoperative delirium shortened the length of hospital stay.

RESULTS

We identified 38 RCTs with interventions ranging from perioperative managements to pharmacological, psychological or multicomponent interventions. Meta-analysis showed dexmedetomidine sedation was associated with less delirium compared to sedation produced by other drugs (two RCTs with 415 patients, pooled risk ratio (RR)=0.39; 95% confidence interval (CI)=0.16 to 0.95). Both typical (three RCTs with 965 patients, RR=0.71; 95% CI=0.54 to 0.93) and atypical antipsychotics (three RCTs with 627 patients, RR=0.36; 95% CI=0.26 to 0.50) decreased delirium occurrence when compared to placebos. Multicomponent interventions (two RCTs with 325 patients, RR=0.71; 95% CI=0.58 to 0.86) were effective in preventing delirium. No difference in the incidences of delirium was found between: neuraxial and general anesthesia (four RCTs with 511 patients, RR=0.99; 95% CI=0.65 to 1.50); epidural and intravenous analgesia (three RCTs with 167 patients, RR=0.93; 95% CI=0.61 to 1.43) or acetylcholinesterase inhibitors and placebo (four RCTs with 242 patients, RR=0.95; 95% CI=0.63 to 1.44). Effective prevention of postoperative delirium did not shorten the length of hospital stay (10 RCTs with 1,636 patients, pooled SMD (standard mean difference)=-0.06; 95% CI=-0.16 to 0.04).

CONCLUSIONS

The included studies showed great inconsistencies in definition, incidence, severity and duration of postoperative delirium. Meta-analysis supported dexmedetomidine sedation, multicomponent interventions and antipsychotics were useful in preventing postoperative delirium.

Future directions of delirium research and management

Delirium is a prevalent organ dysfunction in critically ill patients associated with significant morbidity and mortality, requiring advancements in the clinical and research realms to improve patient outcomes. Increased clinical recognition and utilisation of delirium assessment tools, along with clarification of specific risk factors and presentations in varying patient populations, will be necessary in the future. To improve predictive models for outcomes, the continued development and implementation of delirium assessment tools and severity scoring systems will be required. The interplay between the pathophysiological pathways implicated in delirium and resulting clinical presentations and outcomes will need to guide the development of appropriate prevention and treatment protocols. Multicentre randomised controlled trials of interventional therapies will then need to be performed to test their ability to improve clinical outcomes. Physical and cognitive rehabilitation measures need to be further examined as additional means of improving outcomes from delirium in the hospital setting.

Neurologic Implications of Critical Illness and Organ Dysfunction

Critical illness has consequences for the nervous system. Patients experiencing critical illness are at risk for common global neurologic disturbances, such as delirium, long-term cognitive dysfunction, ICU-acquired weakness, sleep disturbances, recurrent seizures, and coma. In addition, complications related to specific organ dysfunction may be anticipated. Cardiovascular disease presents the possibility for CNS injury after cardiac arrest, sequelae of endocarditis, aberrancies of blood flow autoregulation, and malperfusion. Respiratory disease is known to cause short-term effects of hypoxia and long-term effects after ARDS. Sepsis encephalopathy and sickness behavior syndrome are early signs of infection in patients. In addition, commonly encountered organ dysfunction including uremia, hepatic failure, endocrine, and metabolic disturbances present with neurologic findings which may manifest in the critically ill patient as well.

Year in review 2011: Critical Care--Neurocritical care

Contributions from the neurosciences to Critical Care in 2011 covered an array of topics. We learned about potential biomarkers for, and the effect of cerebral oxygen metabolism on, delirium, in addition to treatment of the latter. A group of investigators studied surface cooling in healthy awake volunteers, and incidence of infection associated with therapeutic hypothermia. The effects of statin and erythropoietin on stroke were revisited, and the role of adhesion molecule in the inflammatory reaction accompanying intracerebral hemorrhage was scrutinized. Biomarkers in subarachnoid hemorrhage and their relationship to vasospasm and outcome, and effect of daylight on outcome in this patient population, as well as a new meta-analysis of statin therapy were among the research in subarachnoid hemorrhage. Moreover, 2011 witnessed the publication of a multidisciplinary consensus conference's recommendations on the critical care management of subarachnoid hemorrhage. Results of studies regarding the diagnosis and vascular complications of meningitis were reported. Traumatic brain injury received its share of articles addressing therapy with hypertonic saline and surgical decompression, the development of coagulopathy, and biomarkers to help with prognostication. Finally, research on the treatment of Guillain-Barre syndrome in children, prediction of long-term need of ventilatory support, and pathophysiology of critical illness polyneuropathy and myopathy were reported.

Prevention and treatment options for postoperative delirium in the elderly

PURPOSE OF REVIEW

To review recent findings and developments in strategies for prevention and treatment of postoperative delirium.

RECENT FINDINGS

Current advances in the field include improved knowledge about predisposing and precipitating factors, evidence for efficacy of multicomponent prevention programmes, refinement of perioperative procedures, and promising pharmacological approaches for prophylaxis and management of postoperative delirium.

SUMMARY

Postoperative delirium is a common and serious complication in elderly patients. Preoperative assessment of risk profiles and tailored multimodal prevention approaches proved effective and should be integrated into clinical practice. Despite promising recent findings, at present, the routine use of pharmacological prophylaxis cannot be recommended. Validated and easy-to-use bedside diagnostic tools are available and should be regularly applied for delirium screening in the first days after surgery. In patients developing delirium, causal conditions and contributing factors need to be identified and addressed. Whereas administration of antipsychotics may represent an option for symptomatic treatment, further studies are needed to evaluate the effects of pharmacological approaches on long-term outcomes in elderly patients with delirium.