Steroid-induced delirium in a patient with asthma: report of one case

Associations between early in-hospital medications and the development of delirium in patients with stroke

OBJECTIVES

Patients hospitalized with stroke develop delirium at higher rates than general hospitalized patients. While several medications are associated with existing delirium, it is unknown whether early medication exposures are associated with subsequent delirium in patients with stroke. Additionally, it is unknown whether delirium identification is associated with changes in the prescription of these medications.

MATERIALS AND METHODS

We conducted a retrospective cohort study of patients admitted to a comprehensive stroke center, who were assessed for delirium by trained nursing staff during clinical care. We analyzed exposures to multiple medication classes in the first 48 h of admission, and compared them between patients who developed delirium >48 hours after admission and those who never developed delirium. Statistical analysis was performed using univariate testing. Multivariable logistic regression was used further to evaluate the significance of univariately significant medications, while controlling for clinical confounders.

RESULTS

1671 unique patients were included in the cohort, of whom 464 (27.8%) developed delirium >48 hours after admission. Delirium was associated with prior exposure to antipsychotics, sedatives, opiates, and antimicrobials. Antipsychotics, sedatives, and antimicrobials remained significantly associated with delirium even after accounting for several clinical covariates. Usage of these medications decreased in the 48 hours following delirium identification, except for atypical antipsychotics, whose use increased. Other medication classes such as steroids, benzodiazepines, and sleep aids were not initially associated with subsequent delirium, but prescription patterns still changed after delirium identification.

CONCLUSIONS

Early exposure to multiple medication classes is associated with the subsequent development of delirium in patients with stroke. Additionally, prescription patterns changed following delirium identification, suggesting that some of the associated medication classes may represent modifiable targets for future delirium prevention strategies, although future study is needed.

Pharmacological Management of Steroid-Induced Psychosis: A Review of Patient Cases

Objective: To review the efficacy and safety of medications used in the management of steroid-induced psychosis. Data Sources: A comprehensive literature search was conducted using PubMed, MEDLINE, ProQuest, and Scopus between May and October 2020 using the following search terminology: "steroid-induced psychosis" OR "corticosteroid-induced psychosis." Study Selection and Data Extraction: Definitive cases, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, were included in this review. Geriatric patients >65 years of age, those with a confounding neurological condition such as a traumatic brain or spinal cord injury, or those with active malignancy were excluded. Data Synthesis: A total of 13 patient cases were included in this review, representing 8 male patients and 5 female patients. The mean age at symptom presentation was 42.5 years. Six patients presented with delusions, 5 presented with hallucinations, and 2 presented with both manifestations; 12 patients were managed with an antipsychotic, with haloperidol being the most commonly prescribed, followed by risperidone. One patient was managed with lithium and clonazepam alone. All patients returned to their psychological baseline upon the discontinuation or decreased dose of steroids in combination with Pharmacological intervention, though the time to resolution of symptoms varied significantly. No notable adverse drug events associated with treatments were reported. Conclusions: Steroid-induced psychosis is a serious adverse effect of corticosteroid therapy; however, management strategies that combine a dose reduction or elimination of steroids, in combination with an antipsychotic medication, are effective in resolving this syndrome.

Asthma and delirium episodes during hospitalization

BACKGROUND

Delirium incidences during hospitalization are an important problem in elderly patients. The problem of delirium episodes in patients with obstructive disease during hospitalization was investigated.

MATERIAL AND METHODS

From a total of 37,156 subjects, the following were randomly selected: 32,261 patients with asthma, 4896 with chronic obstructive pulmonary disease (COPD), and 5455 without obstructive disease. Their ages ranged from 65-95 years, and they were hospitalized between 2006 and 2015. Delirium incidences were monitored based on the International Classification of Disease (ICD)-10 codes and medical documentation.

RESULTS

The delirium episodes during all hospitalizations were independently associated with asthma (odds ratio [OR] = 2.91, confidence interval [CI] = 1.62-5.84), with severe type of asthma (OR = 4.24, CI = 1.94-8.93), partim controlled asthma (OR = 3.1, CI = 1.29-8.46), and uncontrolled asthma (OR = 4.88, CI = 2.12-9.42). It was comparable with COPD as follows: all incidences of delirium during hospitalization (OR = 3.17, CI = 1.42-7.23) or severe COPD (III degree OR = 5.15, CI = 2.01-13.69). Elderly patients with asthma with uncontrolled or partially controlled asthma with a coincidence of advanced age, dementia, or smoking had a greater predisposition to delirium episodes, particularly after surgery. Additionally, delirium incidence caused death more frequently in patients with asthma than in those with COPD.

CONCLUSION

Elderly patients with asthma have a higher risk of delirium episodes during any hospitalization, and, frequently, it ends in death.

Contemporary treatment of children with critical and near-fatal asthma

Asthma is the most common chronic illness in childhood. Although the vast majority of children with acute asthma exacerbations do not require critical care, some fail to respond to standard treatment and require escalation of support. Children with critical or near-fatal asthma require close monitoring for deterioration and may require aggressive treatment strategies. This review examines the available evidence supporting therapies for critical and near-fatal asthma and summarizes the contemporary clinical care of these children. Typical treatment includes parenteral corticosteroids and inhaled or intravenous beta-agonist drugs. For children with an inadequate response to standard therapy, inhaled ipratropium bromide, intravenous magnesium sulfate, methylxanthines, helium-oxygen mixtures, and non-invasive mechanical support can be used. Patients with progressive respiratory failure benefit from mechanical ventilation with a strategy that employs large tidal volumes and low ventilator rates to minimize dynamic hyperinflation, barotrauma, and hypotension. Sedatives, analgesics and a neuromuscular blocker are often necessary in the early phase of treatment to facilitate a state of controlled hypoventilation and permissive hypercapnia. Patients who fail to improve with mechanical ventilation may be considered for less common approaches, such as inhaled anesthetics, bronchoscopy, and extracorporeal life support. This contemporary approach has resulted in extremely low mortality rates, even in children requiring mechanical support.

Psychiatric complications of treatment with corticosteroids: review with case report

Corticosteroids are widely used in modern medicine but can result in troubling psychiatric side-effects. Physicians and other medical professionals should be aware of the potential for these side-effects, possible means of prevention, and efficacious treatments. Herein, we review adult case report data published during the past quarter-century on adverse corticosteroid-induced psychiatric effects, and present a case of corticosteroid-induced psychotic depression. PubMed and PsychLit databases were searched using the terms 'corticosteroids', 'steroids', and the generic names of corticosteroid medications with terms for psychiatric symptoms or syndromes, including psychosis, mania, hypomania, depression, apathy, anxiety, panic, depersonalization, delirium, confusion, hallucinations, delusions, paranoia, cognitive impairment and dementia. Fifty-five cases and a number of clinical trials investigating the incidence and treatment of these psychiatric symptoms and syndromes were identified. Data on incidence, drug dose, risk factors, course of illness and treatment (when present) were tabulated. We conclude that the cumulative data indicate that psychiatric complications of corticosteroid treatment are not rare and range from clinically significant anxiety and insomnia, to severe mood and psychotic disorders, delirium and dementia. While tapering or discontinuation of the corticosteroid treatment may remedy these adverse side-effects, psychotropic medications are often required because of the medical necessity of the corticosteroid or the severity of the psychiatric symptom. Further studies are needed to better understand the deleterious psychiatric effects associated with corticosteroids.

The emotional consequences of corticosteroid use in hematology: preliminary findings

This article presents the findings from a pilot study conducted as a first step in understanding the myriad psychological and psychiatric sequelae stemming from the use of steroids for hematology patients. Descriptions of the side effects experienced by 10 hematology patients undergoing steroid treatment are documented and discussed. Steroid usage can have a range of physical and emotional side effects on patients, including hematology patients. The insights are a serious reminder to all who care for hematology patients that the psychological and psychiatric side effects of steroids need to be taken seriously.