2-Minute Consultation: Reversible Madness: Delirium in Older Patients

Dr. Purvis is a psychiatric pharmacyresident and Dr. Hieber is a clinicalpharmacist at Western Missouri MentalHealth Center in Kansas City.

Fifty years ago, the terms "everyman'spsychosis" and "reversiblemadness" referred to a mentaldisorder to which everyone is susceptible—delirium, an acute confused stateoften overlooked by physicians.¹

Up to 40% of hospitalized elderly patientsexperience delirium, one of themost preventable hospital-acquiredadverse events.^2,3 Failure to uncover theunderlying etiology of delirium resultsin extended stays, increased costs, andincreased morbidity and mortality.^4,5

Delirium commences abruptly and encompassesa broad range of disturbances.These range from hyperactive tohypoactive states, with fluctuations inlevel of consciousness, attention, cognition(memory impairment, disorientation,language disturbance), and perception(visual/tactile hallucinations).Symptoms, including sleep pattern disturbanceand psychomotor behavior,vary throughout the day and generallyresolve within 10 to 12 days.^4,6

The primary goal in management is toidentify the underlying etiology and initiateimmediate interventions to ensurepatient safety. In elderly patients, deliriumis commonly a result of acute illnessor medication, the latter being themost common reversible cause.⁷ Halfof all cases are missed by physicians;thus, pharmacists play a major roleby recommending alternative treatmentstrategies and minimizing the use ofhigh-risk medications (eg, anticholinergics,analgesics).⁸ See Table 11,^9,10 forpotential causes and treatment suggestions.Table 2 provides tips the pharmacistcan implement to help prevent ortreat delirium.

Table 1

Delirium Causes and Treatment Recommendations

Cause

Treatment

Medical

Electrolyte imbalance

Fluids

Endocrine disorders

Treat disorder

Neurologic disease

Treat underlying illness

Substance withdrawal

Treat withdrawal

Sleep deprivation

Optimize environmental cues for day/night, nonpharmacotherapy options for insomnia

Environmental changes

Provide familiar objects, moderate amount of stimuli, educate staff

Other illness(es)

Treat underlying illness(es)

Medications

High-Risk Medications

Analgesics

Anticholinergics

Tricyclic antidepressants

Lithium

Corticosteroids

Dopamine agonists

Sedative hypnotics

Discontinue medication(s) or lower dose; recommend alternative with less deliriogenic risk

Low-Risk Medications

Antidepressants

Anticonvulsants

Cardiovascular agents

Anesthesia

Antiemetics

Antispasmodics

H2-receptor antagonists

Muscle relaxants

Discontinue medication(s) or lower dose; recommend alternative with less deliriogenic risk

Adapted from references 1,9,10.

Studies examining pharmacologicprevention investigated low-dose antipsychotichaloperidol, anticonvulsantgabapentin,and an acetylcholinesteraseinhibitor (ACI), donepezil.^11-13 No trialwas overwhelmingly significant; therefore,using medication to prevent deliriumis not currently recommended.⁴

Acute agitation with delirium maynecessitate short-term pharmacologictreatment; however, if the cause ofdelirium is addressed, further interventionmay not be necessary. Standardpractice involves use of first-generationantipsychotics (primarily haloperidol).^4,14-19 Using lower doses of haloperidol,between 0.5 and 4.5 mg/day,keeps extrapyramidal side effects toa minimum. The evidence for use ofsecond-generation antipsychotics (eg,risperidone, olanzapine, quetiapine, ziprasidone)is expanding.^4,20-32

A recent analysis of haloperidol versusrisperidone, olanzapine, and quetiapinedetermined that all agents havesimilar efficacy in treatment of agitationin delirium.³³ Second-generation anti-psychotics, especially olanzapine and quetiapine, are sedating,which may be beneficial in some situations. Choosing anagent should involve evaluating side effect profiles of eachpotential medication.

Current controversy exists regarding evidence that mortalityis increased in elderly patients receiving antipsychotics.^34-39Clinical significance of these findings is under debate.

Table 2

Pharmacist's Role

Recognize and prevent polypharmacy

Identify potential medication causes

If applicable, recommend alternative therapy

Obtain blood levels when appropriate (eg, lithium, phenytoin)

Adjust dosages in renal or hepatic impairment

Actively participate in medication reconciliation

Recognize potential substance withdrawal

Other medications evaluated in delirium treatment includeACIs, benzodiazepines, and melatonin. Theoretically, ACIsreverse anticholinergic-induced delirium, although the evidenceis limited to case reports.⁴⁰ Benzodiazepines are to beavoided, except in cases of alcohol withdrawal. A study usingalprazolam as treatment for delirium was terminated earlydue to worsening of delirium.¹⁴ A case report uses melatoninto treat delirium, although evidence supporting melatonin'srole in delirium is limited.⁴¹

References

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