Acute delirium is a fairly common occurrence in hospitalized, geriatric patients. It's estimated that 30 to 50 percent of acutely ill elderly persons can be delirious at any point in their hospital stay. Prompt treatment of these patients is critical as delirious patients have a mortality rate of 11 percent. According to new research, treatment with a common medication may actually not be beneficial at all.
Delirium is defined as an acute confusional state that results in the alteration of an individual’s consciousness with a reduction in their ability to focus, sustain or shift attention. And unlike dementia which develops over a long period of time, delirium occurs over hours to days and can wax and wane.
The incidence of delirium in elderly hospitalized patients is very common and there is a step-by-step treatment algorithm for clinicians. The first order of business is to identify the underlying cause and correct it, meaning reviewing the patient’s medication list (polypharmacy in the elderly is not uncommon), perform a focused history and physical, obtain blood samples for laboratory analysis, and check vital signs. If supportive measures and bedside monitors are not effective in ensuring safety of the patient, then an antipsychotic medication may be used for sedation.
A new study, however, published in the Journal of the American Geriatrics Society, recently revealed that a review of medical literature does not support the use of antipsychotics in the elderly for the treatment of acute delirium.
The research included data on 10,877 surgical and medical inpatients who received antipsychotics versus placebo for delirium prevention or treatment. Seven of the 19 studies analyzed revealed no significant effect on delirium incidence in post-operative patients. Based on all 19 studies, the use of antipsychotics was not associated with improvements in the duration, severity or length of stay in an intensive care unit. The authors conclude by stating, “Current evidence does not support the use of antipsychotics for prevention or treatment of delirium.”
Treatment with antipsychotics for acute delirium is considered “off-label” use and the FDA has warned of increased risk of death when antipsychotics are used for treatment of behavioral issues in dementia patients. There is a paucity of sufficient data on the efficacy of antipsychotics in the treatment of delirium.
Further research needs to be conducted to come up with safer and more reliable methods of treating this all-too-common clinical condition in a vulnerable population. With the large baby-boomer population aging there is a critical need for an improved treatment armamentarium. Until then, the focus must remain on preemptive, non-pharmacological interventions to mitigate the risk factors for developing delirium.