Chapter
7: The management of delirium
NB Guidelines and their utility are
discussed under Chapter 10: Education
about delirium
Complex interventions- identification
and treatment
Evaluation of complex interventions
in complex systems by randomised controlled
trials may never be satisfactory.
This is exemplified by the failure
of an important large RCT of systematic
detection and multidisciplinary management
of delirium to show any substantial
difference in outcome compared with
treatment as usual (Cole, McCusker,
Bellavance et al (2002). Apart from
the eight methodological problems
cited by the authors, the management
protocol itself could not be as evidence-based
as that of the Yale study of prevention
(Inouye, Bogardus, Jr., Charpentier
et al (1999). The failure to show
an effect of this intervention has
caused great concern in the world
of delirium research (Rockwood (2002),
and led Anderson and Hewko (2003)
to challenge its findings.
A nurse-led intervention in hip fracture
patients has been shown to reduce
the severity and length of delirium
but not to enhance functional recovery
(Milisen, Foreman, Abraham et al (2001).
These results depart from those of
the well-known Yale study, but there
were methodological differences.
In an unusual study of aftercare
for delirium, Rahkonen and colleagues
have found that continuous nurse specialist
attention and yearly spells in a rehabilitation
centre
significantly reduced increased the
delay in admission to long-term care
(2001) compared to those not followed
up in this way.
The Cochrane review on multidisciplinary
team interventions for delirium in
patients with dementia has been revised,
but its conclusions are the same.
There is no evidence for these interventions,
since the number of studies specifically
aimed at delirium in dementia remains
minimal Britton and Russell (2004).
They make the important point that
since most cases of delirium occur
in dementia, they should be specific
attempts to examine the effectiveness
of interventions in this group, rather
than lumping together patients with
delirium who lack this important predisposing
factor with those that have it.
A specialist 4-bedded delirium unit
in an acute geriatric unit has been
described by Flaherty et al (2003)
with good lighting, low sound levels
and 24-hour presence of mostly specialist
nursing staff. The approaches used
sound like those of good nursing care,
and what is striking is that this
is considered so difficult to achieve
in an acute geriatric inpatient unit
that a special unit is required. This
idea of isolating delirium from good
general care has been challenged by
Modawal (2004).
Naughton, Saltzman, Ramadan et al
(2005) have evaluated the sort of
whole-system intervention that is
necessary to reduce the burden of
delirium in acute medical facilities
for older people. Having established
the prevalence of delirium four days
after admission in a pre-intervention
cohort of 110 patients, together with
data on outcomes, the authors reviewed
the same data for a cohort presenting
to the emergency department in which
physicians and nurses had been specially
trained to identify delirious or cognitively
impaired older adults for selective
admission to an acute geriatric unit
which had just opened. Within the
geriatric unit patients were monitored
by nurses and physicians who had been
exposed to an education programme
about delirium -- its recognition,
management and care. There were two
post intervention cohorts studied
-- one at four months and one at nine
months after the intervention. 154
patients were admitted in the four-month
cohort, and 110 in the nine months
cohort. The cumulative illness rating
scales (Linn, Linn, & Gurel (1968)
scores were similar in all cohorts.
There was a dramatic shift towards
delirious patients being admitted
to the acute geriatric unit. The same
patients in both cohorts received
more antidepressants and neuroleptics,
but fewer benzodiazepines. In the
nine months cohort, patients admitted
to the geriatric unit hand higher
levels of opiate treatment. Patients
with delirium in the two post-intervention
cohorts had significantly lower length
of stay than those admitted to the
general hospital unit.
Phy, Vanness, Melton, III et al (2005)
followed up 466 patients aged 65 or
older admitted for hip fracture, and
examined outcomes before and after
the introduction of a "hospitalist"
service. 236 patients were admitted
before the new service started, the
remainder after. In the normal treatment
group emergency department doctors
chose for clinical reasons to admit
patients either to an orthopaedic
service or a medical service if there
were significant medical problems.
In the intervention phase, a hospitalist
(in the UK general internal physician)
assessed all patients and coordinated
their orthopaedic and medical care.
However, they could not cope with
all patients admitted during intervention
period, and 10 percent were triaged
in the normal way for this service.
Although there was no difference in
baseline characteristics between the
control sample and intervention sample
the outcomes for the latter were significantly
better with shorter length of stay
(both time to surgery and time after
surgery to discharge). However, the
diagnosis of delirium was more frequent
in the intervention group. Since data
was collected mainly from clinical
records, this might represent a better
outcome for the intervention group,
since at least in this group delirium
was recognised and recorded. There
are of course many difficulties in
interpreting studies attempting to
evaluate complex interventions.
Inouye's study did not show any impact
of the multicomponent intervention
on length of stay (1999). By contrast
Lundstrom and colleagues have reorganised
nursing care and instituted an education
programme as an intervention for delirium
recognition and management in one
acute medical ward for older people
ward. They compared a cohort of patients
admitted to this ward with those admitted
to another acute medical ward and
found lower mortality and length of
stay for delirious patients, and lower
overall length of stay (Lundstrom,
Edlund, Karlsson et al (2005). An
important part of their intervention
was training in relationships with
informal carers. Whereas Inouye's
study was concerned with the prevention
of delirium, this present study appeared
to achieve its results by the rapid
recognition and treatment of delirium.
Neither study involved randomisation
to treatment and control groups.
Simple interventions:
treatment
A few more pharmaceutical and other
simple intervention trials and case
reports now grace the delirium literature.
All show positive results with few
adverse effects, but more formal RCTs
are awaited.
Table
2. Simple intervention studies since
publication of book
| Authors |
Medication/intervention |
Type
of study |
Notes |
|
Breitbart, Tremblay, & Gibson (2002)
|
Olanzapine |
Open
label non-controlled n=79 |
Cancer
patients |
|
Leso and Schwartz (2002)
. |
Ziprasidone |
Case
Report |
|
|
Kim, Bader, Kotlyar et al (2003)
|
Quetiapine |
Open
label non-controlled n=12 |
90mg
a day for a mean of 6 days |
|
Horikawa, Yamazaki, Miyamoto et al (2003)
|
Risperidone |
Open
label non-controlled n=10 |
22–81
years old |
|
Liu, Juang, Liang
et
al (2004)
|
Risperidone & haloperidol |
Retrospective
observational n=77 |
|
|
Mittal, Jimerson,
Neely et
al (2004)
|
Risperidone |
Open
label non-controlled n=10 |
37-83
years old |
|
Parellada, Baeza, de Pablo et al (2004)
|
Risperidone |
Open
label non-controlled n=64 |
Mean
age 67 SD 11.4 yrs |
|
Sasaki, Matsuyama, Inoue et al (2003)
|
Quetiapine |
Open
label non-controlled n=12 |
37-84
years old |
|
Skrobik, Bergeron, Dumont et al (2004)
|
Olanzapine & Haloperidol |
Open
label controlled quasi-randomised
n=73 |
18=75
years old- in Intensive Care
Unit.. Few differences in efficacy
but olanzapine
better tolerated (trial funded
by makers of Olanzapine) |
|
Dautzenberg, Mulder, Olde Rikkert et al (2004)
|
Rivastigmine
added to antipsychotics |
Observational
study n=24 compared with 29
controls |
Only
in non-responders to antipsychotics.
Seemed to lead to resolution
in 15 patients |
|
Schneider (2005)
. |
Intravenous
Sodium valproate |
Observational
study n=4 “geriatric” patients |
20mg/kg/day |
|
Han and Kim (2004)
|
Haloperidol
vs
Risperidone |
RCT
n=28 of patients referred to
psychiatrists |
Mean
age 65-66. Not much difference
found |
|
Gagnon, Low, & Schreier (2005)
|
Methylphenidate |
Case
series n=14 with advanced cancer
& hypoactive delirium |
20-30mg
per day; higher doses caused
agitation. No delusion or hallucinations
found. |
|
Milbrandt, Kersten, Kong et al (2005)
|
Haloperidol |
Retrospective
observational cohort n=989 mechanically
ventilated ICU patients. Mean
age c 60 yrs |
8%
received haloperidol and had
lower mortality (logistic regression) |
|
Bourgeois, Koike, Simmons et
al (2005)
. |
Adding
sodium valproate |
Case
series n=6 |
|
Simple interventions:
treatment and prevention
O'Keefe and colleagues have described
how using the MMSE at admission and
six days later is highly predictive
of the diagnosis of incident delirium
(2005). A fall of two or more points
had a sensitivity of 93% and specificity
of 90%t against new delirium on the
second occasion, and a rise of three
points or more had a sensitivity of
77% and a specificity of 75% against
improvement of prevalent delirium
by the second occasion. They recommend
routine MMSEs in acute and medical
care of older people in an attempt
to improve its recognition.
Footnotes
Mayo Smith and colleagues from the
American Society Of Addiction Medicine
have proposed a practice guideline
on the management of alcohol withdrawal
delirium in which they favour sedative-hypnotic
agents over neuroleptic agents, based
on a meta-analysis of nine prospective
controlled trials (2004). However
Klijn and van der Mast (2005) in a
thoughtful letter have challenged
the established view the benzodiazepines
are the first line of treatment for
alcohol withdrawal delirium, pointing
out that the Dutch guidelines van
der Mast, Huyse, & Rosier (2005)
developed by themselves and colleagues
determined that haloperidol should
be the first line of treatment for
suspected alcohol withdrawal delirium.
They suggest that there is a danger
that once alcohol withdrawal has been
diagnosed, other additional causes
of delirium in acute older medical
in patients are ignored
It would seem from the lack of a co-ordinated
approach to delirium in most healthcare
settings that the economic costs of
this disorder are not understood.
The financial cost of delirium has
been estimated in 500 surgical patients
as an excess of almost $1000 per patient
in nursing costs, around $1400 in
technical costs, and around $400 in
professional costs (Franco, Litaker,
Locala et al (2001). Leslie, Zhang,
Bogardus et al (2005) have examined
the long-term economic consequences
of preventing delirium in the Yale
study. They compared total long-term
nursing home costs in an economic
analysis which suggested that, for
long-term nursing home patients, a
saving of 15.5% could be achieved
by the intervention in hospital.
A debate about the use of antimicrobials
in older nursing home patients broke
out temporarily in the Canadian Medical
Association Journal. The view that
these are inappropriately prescribed
(e.g. Walker, McGeer, Simor et al
(2002)) in the absence of urinary
symptoms even when “confusion”
is present (Nicolle (2002) has been
challenged by Miller (2001) It remains
the case that the association between
delirium and urinary tract infection
in the absence of urinary symptoms
or signs (such as frequency) remains
problematic.
Balas, Gale, & Kagan (2004) have
introduced the idea that doulas (unqualified
assistants similar to those used in
childbirth) could be very helpful
in managing intensive care unit delirium.
She lists the several domains of care
in which such a person might be beneficial,
and shows how the usual nursing and
medical procedures leave scope for
many common sense and humane interventions.
As has been suggested elsewhere, the
incidence, prevalence and complications
of delirium are a manifestation of
a whole system failure, and the role
of the doulas may have become unfortunately
vital given the withdrawal of most
qualified nurses from a holistic approach
to patient care.
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