Antipsychotics in the treatment of delirium in older hospitalized adults: a systematic review.

J Am Geriatr Soc. 2011 Nov;59 Suppl 2:S269-76

Authors: Flaherty JH, Gonzales JP, Dong B

Abstract
OBJECTIVES: To examine evidence of the efficacy of antipsychotics in the treatment of delirium in older hospitalized adults.
DESIGN: Systematic literature review.
SETTING: Hospital.
PARTICIPANTS: Older adults with delirium.
MEASUREMENTS: The MEDLINE (January 1980-December 2010) and Cochrane Databases were searched using the keywords "delirium" and "antipsychotics." References of review articles were reviewed to identify additional studies. Study selection criteria included prospective design, more than 10 participants (in treatment arms), mean age 60 and older, standardized criteria for diagnosing delirium, and validated delirium rating scales for reporting outcomes.
RESULTS: Thirteen articles met selection criteria: six single-agent and seven comparison studies. Of these, eight (62%) had fewer than 25 participants in treatment arms, 10 (77%) recruited participants from psychiatry referrals, and eight (62%) did not clearly describe their screening methods. All single-agent studies were open-label studies. Of the comparison studies, five (71%) used randomization, but only one of these (a placebo-controlled study) used adequate allocation concealment methods, and only one other study (comparing two antipsychotics) described a double-blind method in detail. In the only placebo-controlled study (which was stopped early), no statistically significant differences in mean delirium severity scores were found at individual time points (Days 2, 3, 4, 7, 10). The other 12 studies reported improvements in delirium severity or resolution of delirium based on cutoff scores of the scales, but it is not clear from any of these studies what the natural course of delirium would have been without use of antipsychotics.
CONCLUSION: Because of severe methodological limitations, the studies in this review do not support the use of antipsychotics in the treatment of delirium in older hospitalized adults. Additional well-designed randomized placebo-controlled trials are needed.

PMID: 22091572 [PubMed - in process]

Matching the environment to patients with delirium: lessons learned from the delirium room, a restraint-free environment for older hospitalized adults with delirium.

J Am Geriatr Soc. 2011 Nov;59 Suppl 2:S295-300

Authors: Flaherty JH, Little MO

Abstract
Delirium is associated with several negative outcomes and is not always preventable. Current practices for the management of older hospitalized adults with delirium, such as one-on-one sitters, antipsychotic medications, and physical restraints, have limited effectiveness or potential health risks. An alternative management model, called the Delirium Room (DR), is a four-bed patient room (within an Acute Care for Elders (ACE) Unit) that provides 24-hour nursing care, emphasizes nonpharmacological approaches, and is completely free of physical restraints. This article is based on 13 years of experience at two hospitals. The authors have found that a restraint-free environment can be achieved; "tolerate, anticipate, and don't agitate" (the T-A-DA method) are the core principles of the nonpharmacological approach that go beyond the traditional strategies of management (such as reorientation); based on observational data, it appears that negative outcomes associated with delirium, such as loss of function, longer hospital stay, and greater mortality, can be decreased to levels seen in individuals without delirium; and based on limited data, it appears that the rate of falls is at least not higher in the DR than in the ACE unit overall. The limitations of the DR model include lack of randomized controlled trials and the inability to determine which component of the model provides its benefits.

PMID: 22091576 [PubMed - in process]

Postoperative delirium and functional decline after noncardiac surgery.

J Am Geriatr Soc. 2011 Nov;59 Suppl 2:S301-4

Authors: Quinlan N, Rudolph JL

Abstract
OBJECTIVES: To determine whether delirium after noncardiac surgery is associated with functional decline 3 months postoperatively.
DESIGN: Secondary analysis of a prospective study.
SETTING: Thirteen hospitals in eight countries.
PARTICIPANTS: One thousand two hundred eighteen individuals aged 60 and older undergoing noncardiac surgery.
MEASUREMENTS: Participants were interviewed before surgery and 3 months postoperatively using six items pertaining to social and independent function. Functional decline was determined according to a loss in function in at least one item at the 3-month assessment from baseline. Postoperatively, a trained interviewer assessed delirium daily using a standardized battery. The primary outcome of this analysis was an examination of the risk of functional decline with delirium.
RESULTS: Of the 948 participants who completed functional assessment at 3 months, 20% (n = 189) had a decline in function. In unadjusted analysis, postoperative delirium increased the odds of functional decline (odds ratio (OR) = 2.4, 95% confidence interval (CI) = 1.4-4.2). After adjustment for age, sex, education, cognition, and surgery duration, delirium remained associated with functional decline (OR = 2.1, 95% CI = 1.2-3.8).
CONCLUSION: Although considered an acute event, delirium can have lasting functional consequences. Clinicians should give strong consideration to preoperative delirium risk assessment, delirium prevention strategies, and delirium surveillance programs after noncardiac surgery.

PMID: 22091577 [PubMed - in process]