Dr Paul Brown Consultant liaison psychiatrist for older adults 22 nd June 2017 Three aspects of pharmacological management Treat the underlying cause Delirium risk reduction Active treatment of the delirium syndrome ID: 633139
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Slide1
Pharmacological management of delirium
Dr Paul Brown
Consultant liaison psychiatrist for older adults
22
nd
June 2017Slide2Slide3Slide4
Three aspects of pharmacological management
Treat the underlying cause
Delirium risk reduction
Active treatment of the delirium syndromeSlide5
Delirium
DELIRIUMSlide6
Rationale for medication
Common misconceptions exist!
We are not aiming to ‘sedate’ the patient
Some correlates in the delirium syndrome
Dopamine and noradrenaline hyperactivity
Altered serotonin activity
Cholinergic deficiency
Melatonin abnormalities
InflammationSlide7Slide8
Delirium risk reduction
NICE 2010
NICE guidance update 2012
Cochrane Review 2016
Multiple agents of interest
Acetylcholinesterase
inhibitors
Typical antipsychotics
Atypical antipsychotics
Melatonin
GabapentinSlide9
Outcomes of interest
Reduction in delirium incidence
Duration
Severity
Hospital stay
Based on the limited evidence
No recommendations for routine practice
Non-pharmacological approaches critical Slide10
Melatonin of considerable interest
Melatonin abnormalities linked to delirium
Some evidence of benefit in dementia
2x RCT’s, multiple case reports
Inconsistent results
Generally well tolerated in studies
Has a license for primary insomnia
Has anti-inflammatory propertiesSlide11
Active treatment
Outcomes of interest
Achieve complete response
Duration
Severity
NICE guidance 2010
Only three studies included to assess efficacy
Recommends a trial of haloperidol or
olanzapine
Subject to criteria
Short-term treatment Slide12
Cochrane Review 2009 of benzodiazepines
Only one study met inclusion criteria
RCT evaluating lorazepam
Nice guideline update 2012
Single-blinded RCT: emerging evidence of comparable efficacy of olanzapine/risperidone with haloperidol
Doube-blinded RCT evaluating rivastigmineSlide13
Emerging, cautious evidence of equal efficacy between haloperidol and:
Risperidone
Olanzapine
Aripiprazole
Quetiapine
Suggest matching drug feasibility/tolerability to patient
Normal practice remains to follow NICE guidelines where possible Slide14
Prescribing in cardiac disease
Many psychotropic drugs affect the heart
QTc interval very important
Olanzapine low effect
Risperidone low effect
Aripiprazole neglible effect
Haemodynamic factors
Obtain ECG pre-prescriptionSlide15
Prescribing in metabolic disease
Impaired glucose tolerance and diabetes
Metabolic syndrome
Assess cardio-metabolic risk factors
Monitor on treatment
Olanzapine, quetiapine problematic
Better choices
Aripiprazole, haloperidolSlide16
Prescribing in Parkinson’s disease (PD) and
Lewy
Body dementia (LBD
Dopamine antagonism
Can exacerbate
Sx
Review PD medication
Review
AcH
medication
Better choices
Benzodiazepines
QuetiapineOlanzapineAripiprazole Please avoid haloperidol!Slide17
Key points when prescribing
Start slow, go slow ‘think frailty’
Avoid the
common pitfalls
Monitor physical health closely
Daily check for culprit medications (
deliriogenic
drugs)
Regular prescription
vs
PRN
Avoid poly-pharmacy
Off-label prescribing
InteractionsConsistent deliveryTablets/capsules, liquid, oro-dispersable, IM Adults with Incapacity Act/Mental Health Act
Covert prescriptionDaily medication review Slide18
Antipsychotics for delirium in the general hospital setting in consecutive 2453 inpatients: a prospective observational study
Hatta
et al, International Journal of Geriatric Psychiatry 2013
Antipsychotic medications for the treatment of delirium: a systematic review and meta-analysis of randomised controlled trials
Kishi
et al, Journal of Neurology, Neurosurgery and Psychiatry, 2016Slide19
Conclusion
Appropriate use in the right patient can confer benefit
Avoid benzodiazepines in most cases of delirium
More high quality RCT’s are required in this (until recently) neglected field
A rational, evidence based approach will prevent allegations of
‘chemical cosh’!