Pharmacological Management of Delirium in Hospitalized Adults – A Systematic Evidence Review
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BACKGROUND AND OBJECTIVES
Despite the significant burden of delirium among hospitalized adults, there is no approved pharmacologic intervention for delirium. This systematic review evaluates the efficacy and safety of pharmacologic interventions targeting either prevention or management of delirium.
We searched Medline, PubMed, the Cochrane Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) information systems from January 1966 to October 2008. We included randomized, controlled trials comparing pharmacologic compounds either to each other or placebo. We excluded non-comparison trials, studies with patients aged < 18 years, a history of an Axis I psychiatric disorder, and patients with alcohol-related delirium.
Three reviewers independently extracted the data for participants, interventions and outcome measures, and critically appraised each study using the JADAD scale.
We identified 13 studies that met our inclusion criteria and evaluated 15 compounds: second-generation antipsychotics, first-generation antipsychotics, cholinergic enhancers, an antiepileptic agent, an inhaled anesthetic, injectable sedatives, and a benzodiazepine. Four trials evaluated delirium treatment and suggested no differences in efficacy or safety among the evaluated treatment methods (first and second generation antipsychotics). Neither cholinesterase inhibitors nor procholinergic drugs were effective in preventing delirium. Multiple studies, however, suggest either shorter severity and duration, or prevention of delirium with the use of haloperidol, risperidone, gabapentin, or a mixture of sedatives in patients undergoing elective or emergent surgical procedures.
The existing limited data indicates no superiority for second-generation antipsychotics over haloperidol in managing delirium. Although preliminary results suggest delirium prevention may be accomplished through various mechanisms, further studies are necessary to prove effectiveness.
KeywordsHaloperidol Dexmedetomidine Citicoline Quazepam Delirium Prevention
Supported by Grant (K23 AG 26770–01) from the John A. Hartford Foundation, the Atlantic Philanthropies, the Starr Foundation, and the National Institute on Aging.
Conflict(s) of interest
- 2.DeFrances CJ, Hall MJ. 2002 National Hospital Discharge Survey. Advance Data from Vital and Health Statistics, 342. Hyattsville, MD: National Center for Health Statistics; 2004.Google Scholar
- 3.Boustani M, Buttar A. Delirium in hospitalized older adults. Primary care geriatrics, a case-based approach. Editors: R Ham, P. Sloane, G. Warshaw. 5th Edition 2007, Chapter 15: 210–218.Google Scholar
- 6.Trzepacz PT. Is there a final common neural pathway in delirium? Focus on acetylcholine and dopamine. Semin Clin Neuropsychiatry. 2000;5(2):125–31.Google Scholar
- 8.Flacker JM, Lipsitz LA. Neural mechanisms of delirium: current hypotheses and evolving concepts. Erratum appears in J Gerontol A Biol Sci Med Sci. 1999;54(7):B275.Google Scholar
- 9.van der Mast RC, Fekkes D. Serotonin and amino acids: partners in delirium pathophysiology? Clin Neuropsychiatry. 2000;5(2):125–31.Google Scholar
- 23.Diaz V, Rodriguez J, Barrientos P, Serra M, Salina H, et al. Utilizacion de procolinergicos en la prevencion del delirio postoperatorio del adulto mayor sometido a cirugia de fractura de cadera. Ensayo clinico controlado (Use of citicoline in the prevention of delirium in hip fracture surgery in elderly. A randomized controlled trial. Rev Neurol. 2001;33:716–9.PubMedGoogle Scholar
- 29.American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry. 1999;156(5 suppl):1–20.Google Scholar