1
|
Chan L, Corso G. Pharmacological and non-pharmacological prevention and management of delirium in critically ill and palliative patients in the inpatient setting: a review. Front Med (Lausanne) 2024; 11:1403842. [PMID: 39086947 PMCID: PMC11288933 DOI: 10.3389/fmed.2024.1403842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 07/05/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction This review explores delirium in critically ill patients in the inpatient setting, focusing on its prevention and management. It evaluates the efficacy of both current pharmacological and non-pharmacological interventions, aiming to provide a comprehensive overview. Methods A systematic literature search was conducted to identify relevant studies investigating the prevention and management of delirium resulting in a final sample of 26 articles for analysis. Results Of the 26 articles analyzed for this review (N = 8,831 participants) of controlled trials, 16 studies examined the prevention of delirium, 9 explored the treatment of delirium, and 1 investigated both prevention and treatment of delirium. Discussion Among the reviewed studies, there is evidence that non-pharmacologic methods are effective in the prevention of delirium. Evidence regarding pharmacological interventions for delirium prevention is varied and inconclusive, with some indication that atypical antipsychotics like aripiprazole and quetiapine may reduce the incidence of delirium. Regarding the treatment of delirium, there is limited evidence supporting the use of pharmacological agents. Additional double-blinded, randomized, placebo-controlled clinical trials are needed to investigate the efficacy of pharmacologic agents for diverse hospitalized populations.
Collapse
Affiliation(s)
- Leah Chan
- Saint James School of Medicine, Park Ridge, IL, United States
| | | |
Collapse
|
2
|
Hui D, Cheng SY, Paiva CE. Pharmacologic Management of End-of-Life Delirium: Translating Evidence into Practice. Cancers (Basel) 2024; 16:2045. [PMID: 38893163 PMCID: PMC11170992 DOI: 10.3390/cancers16112045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/13/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
End-of-life delirium affects a vast majority of patients before death. It is highly distressing and often associated with restlessness or agitation. Unlike delirium in other settings, it is considered irreversible, and non-pharmacologic measures may be less feasible. The objective of this review is to provide an in-depth discussion of the clinical trials on delirium in the palliative care setting, with a particular focus on studies investigating pharmacologic interventions for end-of-life delirium. To date, only six randomized trials have examined pharmacologic options in palliative care populations, and only two have focused on end-of-life delirium. These studies suggest that neuroleptics and benzodiazepines may be beneficial for the control of the terminal restlessness or agitation associated with end-of-life delirium. However, existing studies have significant methodologic limitations. Further studies are needed to confirm these findings and examine novel therapeutic options to manage this distressing syndrome.
Collapse
Affiliation(s)
- David Hui
- Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Centre, Houston, TX 77030, USA
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei 10617, Taiwan;
| | - Carlos Eduardo Paiva
- Department of Clinical Oncology, Barretos Cancer Hospital, Barretos 1331, SP, Brazil;
| |
Collapse
|
3
|
Van Wicklin SA. Fundamentals of Plastic and Aesthetic Nursing: Postoperative Management of Older Adult Patients Undergoing Plastic Surgical Procedures. Pediatr Phys Ther 2024; 44:99-115. [PMID: 38639967 DOI: 10.1097/psn.0000000000000561] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Affiliation(s)
- Sharon Ann Van Wicklin
- Sharon Ann Van Wicklin, PhD, RN, CNOR, CRNFA(E), CPSN-R, PLNC, ISPAN-F, FAORN, FAAN, is Editor in Chief, Plastic and Aesthetic Nursing, and is a Perioperative and Legal Nurse Consultant, Aurora, CO
| |
Collapse
|
4
|
Kurisu K, Inada S, Maeda I, Nobata H, Ogawa A, Iwase S, Uchida M, Akechi T, Amano K, Nakajima N, Morita T, Sumitani M, Yoshiuchi K. Effectiveness of antipsychotics for managing agitated delirium in patients with advanced cancer: a secondary analysis of a multicenter prospective observational study in Japan (Phase-R). Support Care Cancer 2024; 32:147. [PMID: 38326487 PMCID: PMC10850172 DOI: 10.1007/s00520-024-08352-2] [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: 10/15/2023] [Accepted: 01/31/2024] [Indexed: 02/09/2024]
Abstract
PURPOSE Delirium is a common and serious comorbidity in patients with advanced cancer, necessitating effective management. Nonetheless, effective drugs for managing agitated delirium in patients with advanced cancer remain unclear in real-world settings. Thus, the present study aimed to explore an effective pharmacotherapy for this condition. METHODS We conducted a secondary analysis of a multicenter prospective observational study in Japan. The analysis included patients with advanced cancer who presented with agitated delirium and received pharmacotherapy. Agitation was defined as a score of the Richmond Agitation-Sedation Scale for palliative care (RASS-PAL) of ≥ 1. The outcome was defined as -2 ≤ RASS-PAL ≤ 0 at 72 h after the initiation of pharmacotherapy. Multiple propensity scores were quantified using a multinomial logistic regression model, and adjusted odds ratios (ORs) were calculated for haloperidol, chlorpromazine, olanzapine, quetiapine, and risperidone. RESULTS The analysis included 271 patients with agitated delirium, and 87 (32%) showed -2 ≤ RASS-PAL ≤ 0 on day 3. The propensity score-adjusted OR of olanzapine was statistically significant (OR, 2.91; 95% confidence interval, 1.12 to 7.80; P = 0.030). CONCLUSIONS The findings suggest that olanzapine may effectively improve delirium agitation in patients with advanced cancer.
Collapse
Affiliation(s)
- Ken Kurisu
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuji Inada
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Psychosomatic Medicine, Saitama Cancer Center, Saitama, Japan
| | - Isseki Maeda
- Department of Palliative Care, Senri-Chuo Hospital, Osaka, Japan
| | | | - Asao Ogawa
- Department of Psycho-Oncology Service, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Satoru Iwase
- Department of Palliative Medicine, Saitama Medical University, Iruma, Saitama, Japan
| | - Megumi Uchida
- Department of Psychiatry and Cognitive-Behavioral Medicine, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Aichi, Japan
| | - Tatsuo Akechi
- Department of Psychiatry and Cognitive-Behavioral Medicine, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Aichi, Japan
- Center for Psycho-Oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Aichi, Japan
| | - Koji Amano
- Palliative and Supportive Care Center, Osaka University Hospital, Osaka, Japan
| | - Nobuhisa Nakajima
- Division of Community Medicine and International Medicine, University of the Ryukyus Hospital, Okinawa, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
- Research Association for Community Health, Hamamatsu, Shizuoka, Japan
| | - Masahiko Sumitani
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazuhiro Yoshiuchi
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| |
Collapse
|
5
|
Matsuda Y, Tanimukai H, Inoue S, Hirayama T, Kanno Y, Kitaura Y, Inada S, Sugano K, Yoshimura M, Harashima S, Wada S, Hasegawa T, Okamoto Y, Dotani C, Takeuchi M, Kako J, Sadahiro R, Kishi Y, Uchida M, Ogawa A, Inagaki M, Okuyama T. A revision of JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements. Jpn J Clin Oncol 2023; 53:808-822. [PMID: 37190819 DOI: 10.1093/jjco/hyad042] [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: 02/02/2023] [Accepted: 04/26/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE The Japanese Psycho-Oncology Society and the Japanese Association of Supportive Care in Cancer have recently revised the clinical practice guidelines for delirium in adult cancer patients. This article reports the process of developing the revised guidelines and summarizes the recommendations made. METHODS The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multi-disciplinary members, created three new clinical questions: non-pharmacological intervention and antipsychotics for the prevention of delirium and trazodone for the management of delirium. In addition, systematic reviews of nine existing clinical questions have been updated. Two independent reviewers reviewed the proposed articles. The certainty of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development, and Evaluation system. The modified Delphi method was used to validate the recommended statements. RESULTS This article provides a compendium of the recommendations along with their rationales, as well as a short summary. CONCLUSIONS These revised guidelines will be useful for the prevention, assessment and management of delirium in adult cancer patients in Japan.
Collapse
Affiliation(s)
- Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Hitoshi Tanimukai
- Faculty of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichiro Inoue
- Department of Neuropsychiatry, Okayama University Hospital, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Takatoshi Hirayama
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yusuke Kanno
- Department of Home Health and Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichi Kitaura
- Department of Psychiatry, Panasonic Health Insurance Organization Matsushita Memorial Hospital, Moriguchi, Japan
| | - Shuji Inada
- Department of Psychosomatic Medicine, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Koji Sugano
- Division of Respiratory Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Masafumi Yoshimura
- Department of Occupational Therapy, Faculty of Rehabilitation, Kansai Medical University, Hirakata, Japan
| | - Saki Harashima
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Saho Wada
- Department of Neuropsychiatry, Nippon Medical School Tamanagayama Hospital, Tokyo, Japan
| | - Takaaki Hasegawa
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Yoshiaki Okamoto
- Department of pharmacy, Ashiya Municipal Hospital, Ashiya, Japan
| | - Chikako Dotani
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Mari Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Jun Kako
- College of Nursing Art and Science, University of Hyogo, Akashi, Japan
| | - Ryoichi Sadahiro
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuhiro Kishi
- Department of Psychiatry, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Megumi Uchida
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Asao Ogawa
- Division of Psycho-Oncology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Japan
| | - Masatoshi Inagaki
- Department of Psychiatry, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Toru Okuyama
- Department of Psychiatry/Palliative Care Center, Nagoya City University West Medical Center, Nagoya, Japan
| |
Collapse
|
6
|
Phyland RK, McKay A, Olver J, Walterfang M, Hopwood M, Ponsford M, Ponsford JL. Use of Olanzapine to Treat Agitation in Traumatic Brain Injury: A Series of N-of-One Trials. J Neurotrauma 2023; 40:33-51. [PMID: 35833454 DOI: 10.1089/neu.2022.0139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Agitation is common during post-traumatic amnesia (PTA) following traumatic brain injury (TBI) and is associated with risk of harm to patients and caregivers. Antipsychotics are frequently used to manage agitation in early TBI recovery despite limited evidence to support their efficacy, safety, and impact upon patient outcomes. The sedating and cognitive side effects of these agents are theorized to exacerbate confusion during PTA, leading to prolonged PTA duration and increased agitation. This study, conducted in a subacute inpatient rehabilitation setting, describes the results of a double-blind, randomized, placebo-controlled trial investigating the efficacy of olanzapine for agitation management during PTA, analyzed as an n-of-1 series. Group comparisons were additionally conducted, examining level of agitation; number of agitated days; agitation at discharge, duration, and depth of PTA; length of hospitalization; cognitive outcome; adverse events; and rescue medication use. Eleven agitated participants in PTA (mean [M] age = 39.82 years, standard deviation [SD] = 20.06; mean time post-injury = 46.09 days, SD = 32.75) received oral olanzapine (n = 5) or placebo (n = 6) for the duration of PTA, beginning at a dose of 5 mg/day and titrated every 3 to 4 days to a maximum dose of 20 mg/day. All participants received recommended environmental management for agitation. A significant decrease in agitation with moderate to very large effect (Tau-U effect size = 0.37-0.86) was observed for three of five participants receiving olanzapine, while no significant reduction in agitation over the PTA period was observed for any participant receiving placebo. Effective olanzapine dose ranged from 5-20 mg. Response to treatment was characterized by lower level of agitation and response to treatment within 3 days. In group analyses, participants receiving olanzapine demonstrated poorer orientation and memory during PTA with large effect size (olanzapine, mean = 9.32, SD = 0.69; placebo, M = 10.68, SD = 0.30; p = .009, d = -2.16), and a trend toward longer PTA duration with large effect size (olanzapine, M = 71.96 days, SD = 20.31; placebo, M = 47.50 days, SD = 11.27; p = 0.072, d = 1.26). No further group comparisons were statistically significant. These results suggest that olanzapine can be effective in reducing agitation during PTA, but not universally so. Importantly, administration of olanzapine during PTA may lead to increased patient confusion, possibly prolonging PTA. When utilizing olanzapine, physicians must therefore balance the possible advantages of agitation management with the possibility that the patient may never respond to the medication and may experience increased confusion, longer PTA and potentially poorer outcomes. Further high-quality research is required to support these findings and the efficacy and outcomes associated with the use of any pharmacological agent for the management of agitation during the PTA period.
Collapse
Affiliation(s)
- Ruby K Phyland
- Monash Epworth Rehabilitation Research Center, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne Australia
| | - Adam McKay
- Monash Epworth Rehabilitation Research Center, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne Australia.,Division of Rehabilitation and Mental Health, Epworth HealthCare, Melbourne, Australia
| | - John Olver
- Department of Rehabilitation Medicine, Epworth HealthCare, Melbourne, Australia.,Epworth Monash Rehabilitation Medicine Research Unit, Epworth HealthCare, Melbourne, Australia
| | - Mark Walterfang
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Royal Melbourne Hospital, Melbourne, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Albert Road Clinic Professorial Psychiatry Unit, University of Melbourne, Melbourne, Australia
| | - Michael Ponsford
- Department of Rehabilitation Medicine, Epworth HealthCare, Melbourne, Australia.,Epworth Monash Rehabilitation Medicine Research Unit, Epworth HealthCare, Melbourne, Australia
| | - Jennie L Ponsford
- Monash Epworth Rehabilitation Research Center, Melbourne, Australia.,Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne Australia
| |
Collapse
|
7
|
Sadlonova M, Duque L, Smith D, Madva EN, Amonoo HL, Vogelsang J, Staton SC, von Arnim CAF, Huffman JC, Celano CM. Pharmacologic treatment of delirium symptoms: A systematic review. Gen Hosp Psychiatry 2022; 79:60-75. [PMID: 36375344 DOI: 10.1016/j.genhosppsych.2022.10.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/09/2022] [Accepted: 10/17/2022] [Indexed: 11/04/2022]
Abstract
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).
Collapse
Affiliation(s)
- Monika Sadlonova
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA; Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, Göttingen, Germany; Department of Cardiovascular and Thoracic Surgery, University of Göttingen Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research), Partner site Göttingen, Germany.
| | - Laura Duque
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Diana Smith
- Neurosciences Graduate Program, UC San Diego, La Jolla, CA, USA
| | - Elizabeth N Madva
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Hermioni L Amonoo
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jonathan Vogelsang
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, McLean Hospital, Boston, MA, USA
| | - Sophie C Staton
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | | | - Jeff C Huffman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Christopher M Celano
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
8
|
Mossie A, Regasa T, Neme D, Awoke Z, Zemedkun A, Hailu S. Evidence-Based Guideline on Management of Postoperative Delirium in Older People for Low Resource Setting: Systematic Review Article. Int J Gen Med 2022; 15:4053-4065. [PMID: 35444455 PMCID: PMC9014957 DOI: 10.2147/ijgm.s349232] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/05/2022] [Indexed: 12/28/2022] Open
Abstract
Background Postoperative delirium is the highest prevalence and life-threatening complication following geriatric surgery. The overall incidence rate varies from 5% to 52% of hospitalized surgical patients based on the type of surgery that often began in the postanesthesia care unit and continues up to 5 days post-surgery. Postoperative delirium manifests as a hypoactive, hyperactive and mixed subtype. The mechanism of delirium development is not clear, but it is accepted that delirium is a result of the patient's underlying vulnerabilities or risk factors combined with an outside stressor such as infection or surgery. Objective To develop evidence-based recommendations for the prevention, diagnosis, and treatment of postoperative delirium. Methods Literature was searched from PubMed, CINAH, Google Scholar, and Cochrane databases that are published from 2010 to 2021 by formulating inclusion and exclusion criteria. Filtering was made depending on methodological quality, outcome, and data on population. Finally, 11 meta-analysis, 11 systematic reviews, 7 interventional studies, 11 observational studies, and recommendations of the previous clinical practice guideline developed by the American and European are included in this review. Results A total of 43 studies were considered in this evaluation. The development of this guideline was based on nine studies on risk stratification for postoperative delirium, eighteen studies on risk minimization and prevention for postoperative delirium, five studies on diagnosis for postoperative delirium, and eleven studies on treatments for postoperative delirium. Conclusion Postoperative delirium management can be categorized into risk assessment, risk minimization, early diagnosis, and treatment. Early diagnosis is critical to trigger focused and effective treatment. Non-pharmacological interventions are the first-line management for both hypoactive and hyperactive postoperative with considering contributory factors and underlying causes. Antipsychotics should only be used for hyperactive delirium individuals who try to harm themselves. Current evidence suggested that dexmedetomidine can be used as a treatment option for postoperative delirium.
Collapse
Affiliation(s)
- Addisu Mossie
- Anesthesia Department, Hawassa University, Hawassa, Ethiopia
| | - Teshome Regasa
- Anesthesia Department, Dilla University, Dilla, Ethiopia
| | - Derartu Neme
- Anesthesia Department, Dilla University, Dilla, Ethiopia
| | - Zemedu Awoke
- Anesthesia Department, Dilla University, Dilla, Ethiopia
| | | | - Seyoum Hailu
- Anesthesia Department, Dilla University, Dilla, Ethiopia
| |
Collapse
|
9
|
Agar MR, Siddiqi N, Hosie A, Boland JW, Johnson MJ, Featherstone I, Lawlor PG, Bush SH, Page V, Amgarth-Duff I, Garcia M, Disalvo D, Rose L. Outcomes and measures of delirium interventional studies in palliative care to inform a core outcome set: A systematic review. Palliat Med 2021; 35:1761-1775. [PMID: 34448431 DOI: 10.1177/02692163211040186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Trials of interventions for delirium in various patient populations report disparate outcomes and measures but little is known about those used in palliative care trials. A core outcome set promotes consistency of outcome selection and measurement. AIM To inform core outcome set development by examining outcomes, their definitions, measures and time-points in published palliative care studies of delirium prevention or treatment delirium interventions. DESIGN Prospectively registered systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. DATA SOURCES We searched six electronic databases (1980-November 2020) for original studies, three for relevant reviews and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We included randomised, quasi-randomised and non-randomised intervention studies of pharmacological and non-pharmacological delirium prevention and/or treatment interventions. RESULTS From 13/3244 studies (2863 adult participants), we identified 9 delirium-specific and 13 non-delirium specific outcome domains within eight Core Outcome Measures in Effectiveness Trials (COMET) taxonomy categories. There were multiple and varied outcomes and time points in each domain. The commonest delirium specific outcome was delirium severity (n = 7), commonly using the Memorial Delirium Assessment Scale (6/8 studies, 75%). Four studies reported delirium incidence. Non-delirium specific outcomes included mortality, agitation, adverse events, other symptoms and quality of life. CONCLUSION The review identified few delirium interventions with heterogeneity in outcomes, their definition and measurement, highlighting the need for a uniform approach. Findings will inform the next stage to develop consensus for a core outcome set to inform delirium interventional palliative care research.
Collapse
Affiliation(s)
- Meera R Agar
- IMPACCT Centre (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,South West Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.,Ingham Institute of Applied Medical Research, Sydney, NSW, Australia
| | - Najma Siddiqi
- Hull York Medical School, Department of Health Sciences, University of York, York, UK.,Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Annmarie Hosie
- IMPACCT Centre (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,School of Nursing Sydney, The University of Notre Dame Australia, Darlinghurst, NSW, Australia.,St Vincent's Health Network Sydney, East Sydney, NSW, Australia
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Imogen Featherstone
- Hull York Medical School, Department of Health Sciences, University of York, York, UK
| | - Peter G Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Valerie Page
- Watford General Hospital, Watford, Hertfordshire, UK
| | - Ingrid Amgarth-Duff
- IMPACCT Centre (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Maja Garcia
- IMPACCT Centre (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Domenica Disalvo
- IMPACCT Centre (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | | |
Collapse
|
10
|
Finucane AM, Jones L, Leurent B, Sampson EL, Stone P, Tookman A, Candy B. Drug therapy for delirium in terminally ill adults. Cochrane Database Syst Rev 2020; 1:CD004770. [PMID: 31960954 PMCID: PMC6984445 DOI: 10.1002/14651858.cd004770.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Delirium is a syndrome characterised by an acute disturbance of attention and awareness which develops over a short time period and fluctuates in severity over the course of the day. It is commonly experienced during inpatient admission in the terminal phase of illness. It can cause symptoms such as agitation and hallucinations and is distressing for terminally ill people, their families and staff. Delirium may arise from any number of causes and treatment should aim to address these causes. When this is not possible, or treatment is unsuccessful, drug therapy to manage the symptoms may become necessary. This is the second update of the review first published in 2004. OBJECTIVES To evaluate the effectiveness and safety of drug therapies to manage delirium symptoms in terminally ill adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO from inception to July 2019, reference lists of retrieved papers, and online trial registries. SELECTION CRITERIA We included randomised controlled trials of drug therapies in any dose by any route, compared to another drug therapy, a non-pharmacological approach, placebo, standard care or wait-list control, for the management of delirium symptoms in terminally ill adults (18 years or older). DATA COLLECTION AND ANALYSIS We independently screened citations, extracted data and assessed risk of bias. Primary outcomes were delirium symptoms; agitation score; adverse events. Secondary outcomes were: use of rescue medication; cognitive status; survival. We applied the GRADE approach to assess the overall quality of the evidence for each outcome and we include eight 'Summary of findings' tables. MAIN RESULTS We included four studies (three new to this update), with 399 participants. Most participants had advanced cancer or advanced AIDS, and mild- to moderate-severity delirium. Meta-analysis was not possible because no two studies examined the same comparison. Each study was at high risk of bias for at least one criterion. Most evidence was low to very low quality, downgraded due to very serious study limitations, imprecision or because there were so few data. Most studies reported delirium symptoms; two reported agitation scores; three reported adverse events with data on extrapyramidal effects; and none reported serious adverse events. 1. Haloperidol versus placebo There may be little to no difference between placebo and haloperidol in delirium symptoms within 24 hours (mean difference (MD) 0.34, 95% confidence interval (CI) -0.07 to 0.75; 133 participants). Haloperidol may slightly worsen delirium symptoms compared with placebo at 48 hours (MD 0.49, 95% CI 0.10 to 0.88; 123 participants with mild- to moderate-severity delirium). Haloperidol may reduce agitation slightly compared with placebo between 24 and 48 hours (MD -0.14, 95% -0.28 to -0.00; 123 participants with mild- to moderate-severity delirium). Haloperidol probably increases extrapyramidal adverse effects compared with placebo (MD 0.79, 95% CI 0.17 to 1.41; 123 participants with mild- to moderate-severity delirium). 2. Haloperidol versus risperidone There may be little to no difference in delirium symptoms with haloperidol compared with risperidone within 24 hours (MD -0.42, 95% CI -0.90 to 0.06; 126 participants) or 48 hours (MD -0.36, 95% CI -0.92 to 0.20; 106 participants with mild- to moderate-severity delirium). Agitation scores and adverse events were not reported for this comparison. 3. Haloperidol versus olanzapine We are uncertain whether haloperidol reduces delirium symptoms compared with olanzapine within 24 hours (MD 2.36, 95% CI -0.75 to 5.47; 28 participants) or 48 hours (MD 1.90, 95% CI -1.50 to 5.30, 24 participants). Agitation scores and adverse events were not reported for this comparison. 4. Risperidone versus placebo Risperidone may slightly worsen delirium symptoms compared with placebo within 24 hours (MD 0.76, 95% CI 0.30 to 1.22; 129 participants); and at 48 hours (MD 0.85, 95% CI 0.32 to 1.38; 111 participants with mild- to moderate-severity delirium). There may be little to no difference in agitation with risperidone compared with placebo between 24 and 48 hours (MD -0.05, 95% CI -0.19 to 0.09; 111 participants with mild- to moderate-severity delirium). Risperidone may increase extrapyramidal adverse effects compared with placebo (MD 0.73 95% CI 0.09 to 1.37; 111 participants with mild- to moderate-severity delirium). 5. Lorazepam plus haloperidol versus placebo plus haloperidol We are uncertain whether lorazepam plus haloperidol compared with placebo plus haloperidol improves delirium symptoms within 24 hours (MD 2.10, 95% CI -1.00 to 5.20; 50 participants with moderate to severe delirium), reduces agitation within 24 hours (MD 1.90, 95% CI 0.90 to 2.80; 52 participants), or increases adverse events (RR 0.70, 95% CI -0.19 to 2.63; 31 participants with moderate to severe delirium). 6. Haloperidol versus chlorpromazine We are uncertain whether haloperidol reduces delirium symptoms compared with chlorpromazine at 48 hours (MD 0.37, 95% CI -4.58 to 5.32; 24 participants). Agitation scores were not reported. We are uncertain whether haloperidol increases adverse events compared with chlorpromazine (MD 0.46, 95% CI -4.22 to 5.14; 24 participants). 7. Haloperidol versus lorazepam We are uncertain whether haloperidol reduces delirium symptoms compared with lorazepam at 48 hours (MD -4.88, 95% CI -9.70 to 0.06; 17 participants). Agitation scores were not reported. We are uncertain whether haloperidol increases adverse events compared with lorazepam (MD -6.66, 95% CI -14.85 to 1.53; 17 participants). 8. Lorazepam versus chlorpromazine We are uncertain whether lorazepam reduces delirium symptoms compared with chlorpromazine at 48 hours (MD 5.25, 95% CI 0.38 to 10.12; 19 participants), or increases adverse events (MD 7.12, 95% CI 1.08 to 15.32; 18 participants). Agitation scores were not reported. SECONDARY OUTCOMES use of rescue medication, cognitive impairment, survival There were insufficient data to draw conclusions or assess GRADE. AUTHORS' CONCLUSIONS We found no high-quality evidence to support or refute the use of drug therapy for delirium symptoms in terminally ill adults. We found low-quality evidence that risperidone or haloperidol may slightly worsen delirium symptoms of mild to moderate severity for terminally ill people compared with placebo. We found moderate- to low-quality evidence that haloperidol and risperidone may slightly increase extrapyramidal adverse events for people with mild- to moderate-severity delirium. Given the small number of studies and participants on which current evidence is based, further research is essential.
Collapse
Affiliation(s)
- Anne M Finucane
- Marie Curie Hospice Edinburgh45 Frogston Road WestEdinburghUKEH10 7DR
- University of EdinburghUsher InstituteEdinburghUK
| | - Louise Jones
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | - Baptiste Leurent
- London School of Hygiene and Tropical MedicineDepartment of Medical StatisticsLondonUK
| | - Elizabeth L Sampson
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | - Patrick Stone
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | | | - Bridget Candy
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | | |
Collapse
|