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Delirium in Old Age
August
2005 Update
Chapter
8: The prevention of delirium
NB Educational interventions
are discussed in the update to Chapter 10:
Education about Delirium
Complex preventative interventions
Further analysis of the costs of the Yale
multicomponent intervention trial in the
prevention of delirium showed that intervention
protocol adherence was a crucial factor
in its efficacy (Inouye, Bogardus, Jr.,
Williams et al (2003). Overall, it was cost-effective
in preventing delirium in those at moderate
but not high risk (Rizzo, Bogardus, Jr.,
Leo-Summers et al (2001). Conversely, 6-month
follow-up of this sample showed few lasting
benefits of this intervention for the group
as a whole, but high-risk patients seemed
to have better self-rated health and functional
status in the intervention group compared
with the control group (Bogardus, Desai,
Williams et al (2003). However Leslie, Zhang,
Bogardus et al (2005) have examined the
long-term economic consequences of preventing
delirium in this sample. 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. Marcantonio and colleagues (2001)
have reported in a randomised double-blind
trial that geriatric assessment and treatment
successfully reduced the incidence of delirium
(especially severe delirium) in hip fracture
patients, but not its course or outcome.
Simple preventative interventions
| Authors |
Medication/intervention |
Type
of study |
Notes |
|
Dautzenberg, Mulder, Olde Rikkert et al (2004)
|
Rivastigmine |
Retrospective
cohort study n=11 compared with 29
controls |
Patients
on rivastigmine seemed less likely
to develop delirium |
|
Moretti, Torre, Antonello
et
al (2004)
|
Rivastigmine
vs Aspirin |
Observational
prospective cohort study n=246 with
vascular dementia |
Opaque
methodology. 42% on rivastigmine developed
delirium in 24 months, 62% on aspirin. |
|
McCaffrey and Locsin (2005)
|
Passive
music therapy (“easy listening” type) |
Non-blind
RCT. Elective hip/knee surgery patients
over 65 years n=66 |
Significant
beneficial effect on no. of incident
observed delirium episodes. Calmed
staff and relatives too! |
Footnotes
Adunsky et al (2002) studied the use of
opiate analgesics in 302 patients admitted
to an orthogeriatric ward with a hip fracture.
Although pain is a known risk factor for
delirium (Morrison, Sean, Magaziner et al
(2003), patients with cognitive impairment
or delirium received significantly less
analgesics than intact patients. Adequate
analgesia seems to be an important preventative
factor in delirium, although the choice
of analgesia may be as important (Adunsky,
Levy, Heim et al (2002)
An unusual means of preventing delirium
is reported from Japan by Aizawa, Kanai,
Saikawa et al (2002). Possibly related to
observations on the emergence of delirium
after sleep deprivation (Shiihara, Nogami,
Chigira et al (2001), they carried out a
randomized controlled trial of a continuous
intravenous infusion of benzodiazepines
and, interestingly, pethidine (meperidene),
overnight in 40 older patients for 3 nights
after gastrointestinal surgery. Apart from
morning drowsiness, there seemed to be few
ill-effects. A significant reduction in
the incidence of delirium was found. Given
what is suspected about meperidene and delirium
(Adunsky, Levy, Heim, Mizrahi, and Arad
(2002) perhaps even better results might
have been achieved with a different analgesic.
In a German study ultrasound thigh muscle
mass measurement came only second to immobility
as an independent predictor of delirium
risk (Weinrebe, Guneysu, & Welz-Barth
(2002) . In Adunsky et al’s observational
study poor mobility and previous cognitive
impairment were the main risk factors for
post-hip fracture pre-operative delirium
(2003).
Reference List Chapter
8
Adunsky, Abraham, Levy, Rami, Heim, Michael,
et al (2002)
Meperidine analgesia
and delirium in aged hip fracture patients.
Archives of Gerontology & Geriatrics,
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McCaffrey, R and Locsin, R (2005) The effect of music listening on acute
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elective hip and knee surgery. International
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P., Antonello,
R. M., et al (2004) Cholinesterase inhibition as a possible therapy for delirium
in vascular dementia: a controlled, open
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L.,
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Shiihara, Y., Nogami,
T., Chigira, M.,
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Sleep-wake rhythm during stay in an intensive
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Weinrebe, W., Guneysu,
S., and Welz-Barth,
A. (2002) Low muscle mass of the thigh is
significantly correlated with delirium and
worse functional outcome in older medical
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