Delirium on Medical Inpatients

[cbrons]

Heard a lecture from a noon conference via YouTube on treating delirium in medical inpatients. It was given by a psychiatrist. He basically said that anti-psychotics shouldn't be given, and that there is no real pharmacologic treatment that should be ordered in most cases. (Granted I was driving in a car with 2 noisy kids and listening on headphones so perhaps I misheard some of the nuance).

His reasoning was that the evidentiary basis is very low and the society for critical care medicine doesn't recommend Haldol for delirium. I'm confused about this and wanted some perspectives from psychiatrists on how to treat both hypoactive and hyperactive delirium of the type you might be consulted about on Night float (on the medicine service).

Lecture was here in case anyone is interested - Delirium with Dr. Zachary Sager

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[Stagg737]

Heard a lecture from a noon conference via YouTube on treating delirium in medical inpatients. It was given by a psychiatrist. He basically said that anti-psychotics shouldn't be given, and that there is no real pharmacologic treatment that should be ordered in most cases. (Granted I was driving in a car with 2 noisy kids and listening on headphones so perhaps I misheard some of the nuance).

His reasoning was that the evidentiary basis is very low and the society for critical care medicine doesn't recommend Haldol for delirium. I'm confused about this and wanted some perspectives from psychiatrists on how to treat both hypoactive and hyperactive delirium of the type you might be consulted about on Night float (on the medicine service).

Lecture was here in case anyone is interested - Delirium with Dr. Zachary Sager

Not a psychiatrist, but I did have to look up delirium treatment protocol for a presentation during my last psych rotation and found the same thing your lecturer did. All the recent evidence I saw pointed to antipsychotics having little to no impact on rates of delirium, length/severity of the delirium, or hospital LoS. Best treatment was prophylactic and included altering which meds were used during anesthesia, early mobilization of patients when possible, appropriate sleep schedule, proper hydration, etc. I'll ask my previous attending for the presentation and provide links to the studies cited if I can.

Would also be very interested to hear what interventions the residents and attendings have found useful in treating delirium in medical patients once it has been identified.

 

[COXblocker]

Pending listening to the lecture, here's my 2c on some key literature on the topic.

• Friedman JI, Soleimani L, McGonigle DP, Egol C, Silverstein JH. Pharmacological Treatments of Non-Substance-Withdrawal Delirium: A Systematic Review of Prospective Trials. American Journal of Psychiatry. 2014;171(2):151-9.
  • Yes preventing is better. There is a brief mention of some studies of treatment which found Seroquel somewhat helpful, but the non-superiority studies and the studies supporting Seroquel are suspect in quality. Take away is that if you can implement certain strategies you can prevent a lot of delirium
• Inouye SK. Delirium in Older Persons. New England Journal of Medicine. 2006;354(11):1157-65
  • A good "advanced med student" level overview of delirium. Casually pull this out on your away rotation. Pay special attention to the nonpharmacologic treatment strategies, which should always go in a consult recommendation
• Reade MC, Finfer S. Sedation and Delirium in the Intensive Care Unit. New England Journal of Medicine. 2014;370(5):444-54.
  
  • Another good overview
• Neufeld KJ, Yue J, Robinson TN, Inouye SK, Needham DM. Antipsychotic Medication for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta-Analysis. Journal of the American Geriatrics Society. 2016;64(4):705-14.
  • I think what all the fuss is about in the current anti-antipsychotic movement. It seems that again, prevention is key. The treatment studies included in the meta-analysis suffer from poor signal to noise, and when you combine them, you almost certainly lose efficacy of antipsychotics in specific groups of patients. I would say that this study has a high potential of making a beta error and would conclude instead that antipsychotics are at least not worse than doing nothing.
• Kishi T, Hirota T, Matsunaga S, Iwata N. Antipsychotic medications for the treatment of delirium: a systematic review and meta-analysis of randomised controlled trials. Journal of Neurology, Neurosurgery & Psychiatry. 2016 July 1, 2016;87(7):767-74.
  • Interestingly, this same author wrote an article in the Journal of Evidence-Based Psychiatry summarizing the article above. This review shows efficacy of Haloperidol and SGAs (Zyprexa > Seroquel) but I would argue borders on an alpha error! Some of the studies included had as endpoints pretty low thresholds for response and may over-estimate the effect of medication.
• Maldonado JR. Delirium in the Acute Care Setting: Characteristics, Diagnosis and Treatment. Critical Care Clinics. 2008;24(4):657-722.
  • If you just casually mention this article people think you're smart. I use the list of potential meds that can cause delirium as a starting point for seeing if we can help by decreasing or changing a med. It's surprising how often I find a patient with delirium and a scopolamine patch. Also, the treatment algorithm on pg 683 is golden. Altogether it's difficult to find where Maldonado's personal experience is speaking and where there is evidence for his recommendations.
• Sher Y, Miller Cramer AC, Ament A, Lolak S, Maldonado JR. Valproic Acid for Treatment of Hyperactive or Mixed Delirium: Rationale and Literature Review. Psychosomatics. 2015;56(6):615-25.
  
  • Again you see Maldonado's explanatory style maybe extending beyond what the evidence suggests, but this gives a somewhat convincing argument for using VPA in the type of delirium you actually get called on.

Take away: I am not convinced that antipsychotics (+/- VPA) are not useful for some patients. However, these meds are treating symptoms and making staff's job easier. We need to do a better job of preventing delirium, using non-pharmacological interventions early, and recognizing hypoactive delirium. A failure to do so increases morbidity, mortality, cost. I will continue to suggest meds to help with the symptoms, but I am not "treating" delerium.

 

[COXblocker]

And now after watching the video...I agree 100%. I'd add this newer article to my "delirium sucks" folder.

Davis DJ, Muniz-Terrera G, Keage HD, et al. Association of delirium with cognitive decline in late life: A neuropathologic study of 3 population-based cohort studies. JAMA Psychiatry. 2017;74(3):244-51.

 

[SourceOfDenial]

The lecture is mine, so I'll respond, ha. I'm saying that antipsychotics are not a treatment for delirium, but rather a treatment for the agitation associated with delirium. So you shouldn't never use antipsychotics, but be clear why you are using them.

Example, a recent patient who presented to inpatient psych with what looked like an agitated delirium. Labwork unremarkable, eeg was borderline normal(difficult with movement artifact), unable to obtain mri. Has comorbid COPD so he would get agitated, hypoxic, and more confused. Initially it was unclear if it was withdrawal(alcohol hx) so benzos were tried and barbiturates with little effect, and then small doses of antipsychotics. I used the antipsychotics to help agitation to prevent him from injuring himself, not to treat delirium. The antipsychotics did little so we moved him to the ICU and used precedex for agitation control.

The JAMA article I speak of is an interesting one, but my more nuanced opinion is of course the people die, they are terminally delirious. Also, that study is hard to extrapolate because the population is so specific. Terminal delirium is absolutely a place you want to use antipsychotics.

My big thing with the lecture is: use environmental treatments, limit medications, get folks out of the ICU, regularly use rating scales, use EEGs more to help dx, and if you have to, use antipsychotics sparingly to treat agitation when you are fearful that not treating will injure the patient.

 

[nitemagi]

Find and treat the underlying condition. APs for symptom control in the meantime.

 

[Salpingo]

Heard a lecture from a noon conference via YouTube on treating delirium in medical inpatients. It was given by a psychiatrist. He basically said that anti-psychotics shouldn't be given, and that there is no real pharmacologic treatment that should be ordered in most cases. (Granted I was driving in a car with 2 noisy kids and listening on headphones so perhaps I misheard some of the nuance).

His reasoning was that the evidentiary basis is very low and the society for critical care medicine doesn't recommend Haldol for delirium. I'm confused about this and wanted some perspectives from psychiatrists on how to treat both hypoactive and hyperactive delirium of the type you might be consulted about on Night float (on the medicine service).

Lecture was here in case anyone is interested - Delirium with Dr. Zachary Sager

In addition to the excellent posts above, I'd like to mention some practical considerations when dealing with people (if it wasn't for those darn people, this job would be great).

The next time a nurse pages you about a patient tearing up the floor (or his Foley), try telling them to play the patient's favorite song, or put up some pictures of their family, or mobilize them earlier. Yes, they're all real interventions, but the good staff members have already exhausted them before they call you, and the bad ones won't bother regardless. Similarly, tell a family member they're going to have to watch their loved one writhe up and out of bed until the underlying disorder is treated (which is often never discovered). That means they have to wait for the MRI, which the patient isn't tolerating because, well, they're delirious.

So even if you're 100% cynical, there's a role for the antipsychotic as a locus of control that helps the people around the delirious patient, one that isn't a benzo or opiate. And you can potentially pick the antipsychotic with best side effect profile for that given patient.

If you're only 50% cynical, and feel antipsychotics are only effective when used appropriately, it is important to learn when to put on the brakes. Often we're consulted when the patient has been slammed with several days of escalating doses that are just reaching steady state, or 5 different alternating agents.

 

[cbrons]

The lecture is mine, so I'll respond, ha. I'm saying that antipsychotics are not a treatment for delirium, but rather a treatment for the agitation associated with delirium. So you shouldn't never use antipsychotics, but be clear why you are using them.

Example, a recent patient who presented to inpatient psych with what looked like an agitated delirium. Labwork unremarkable, eeg was borderline normal(difficult with movement artifact), unable to obtain mri. Has comorbid COPD so he would get agitated, hypoxic, and more confused. Initially it was unclear if it was withdrawal(alcohol hx) so benzos were tried and barbiturates with little effect, and then small doses of antipsychotics. I used the antipsychotics to help agitation to prevent him from injuring himself, not to treat delirium. The antipsychotics did little so we moved him to the ICU and used precedex for agitation control.

The JAMA article I speak of is an interesting one, but my more nuanced opinion is of course the people die, they are terminally delirious. Also, that study is hard to extrapolate because the population is so specific. Terminal delirium is absolutely a place you want to use antipsychotics.

My big thing with the lecture is: use environmental treatments, limit medications, get folks out of the ICU, regularly use rating scales, use EEGs more to help dx, and if you have to, use antipsychotics sparingly to treat agitation when you are fearful that not treating will injure the patient.

Thanks so much for the replies.

What is your typical protocol before giving someone IV haldol? Does your hospital require them placed on telemetry?
If not on telemetry, how long after administering it do you run an EKG?

In this textbook, I found the following guidelines, which I think seem rather extreme regarding electrolytes:

TABLE 81-3 Considerations When Using Medications for Symptomatic Treatment in Delirious Patients†

• 
  There is little evidence that any medication can prevent or shorten the duration of delirium.
  
  
• Benzodiazepines should be avoided unless specifically indicated (ie, alcohol withdrawal, serotonin syndrome) as they often worsen delirium.
  
  
• Antipsychotics are often used to treat the following symptoms associated with delirium:
  • Agitation or violence that places the patient or staff at risk of harm.
    
    
  • Hallucinations, delusions, fearfulness, or sleep cycle disruption.
• Before starting an antipsychotic:
  • Review/calculate QTc on ECG.
    
    
  • Check serum potassium (K+), magnesium (Mg++), and calcium (Ca++).
• If QTc >450 msec in men or >470 msec in women, weigh the risks and benefits of starting a QTc-prolonging medication, such as an antipsychotic and do the following:
  • If possible, reduce dose or discontinue/substitute other prescribed medications that may be contributing to prolonged QTc.
    
    
  • Keep serum electrolytes K+ >4 and Mg++ >2 mEq/L††. Normalize serum calcium.
• Antipsychotic use for the treatment of agitation in delirium is a temporary measure; ongoing use should be re-assessed daily.
  • Select an antipsychotic based on efficacy, available administration route (ie, by mouth [po], intravenous [IV], and intramuscular formulations [IM]) and cost.
    
    
  • Use the lowest effective dose to manage symptoms (eg, starting dose of haloperidol: 1–2 mg IV or 2–5 mg po in adults with severe agitation, with 50% dose reduction for frail or elderly patients). Repeat within 30 minutes if no effect is seen.
    
    
  • IM and IV administration of haloperidol results in double the peak drug levels compared to oral administration (ie, 1 mg of haloperidol IV = 2 mg po).
• Monitor for extrapyramidal side effects, such a sakathisia, dystonia, and Parkinsonian symptoms.
  • Akathisia—is a subjective sense of “inner restlessness” or “inability to stay still”; this side effect can be mistaken for worsening agitation because of the patient’s motor restlessness.
    
    
  • Dystonia—includes oculogyric crisis (contraction of extraocular muscles resulting in sustained deviation of the eyes), or dystonia of neck or trunk muscles or of pharynx. Dystonia is very frightening, painful and can be life threatening (particularly pharyngeal dystonia). It should be treated immediately with diphenhydramine 25–50 mg IV or IM, or benztropine1–2 mg IV or IM.
    
    
  • Examinemuscular tone for cogwheel rigidity or tremor daily in elbow and wrist joints.
    
    
  • If side effects occur and the patient is on a high potency antipsychotic (such as, haloperidol or risperidone), lower the dose, or stop the medication, or consider switching to a lower potency medication (such as, olanzapine or quetiapine).
• Continue to search for and treat the underlying causes of delirium.
  
  
• Once the patient’s agitation and sleep disruption have fully resolved, taper antipsychotic medication over a period of days with a goal, when feasible, to discontinue all antipsychotics before hospital discharge.

Neufeld KJ, Max LK, Koyi MB, Needham DM. Delirium. In: McKean SC, Ross JJ, Dressler DD, Scheurer DB. eds. Principles and Practice of Hospital Medicine, 2e New York, NY: McGraw-Hill; .

 

[slappy]

What are you all talking about? Atypicals are safe and effective in treating not only agitation but also delirium. I've seen multiple small RCTs to that effect.

 

[cbrons]

What are you all talking about? Atypicals are safe and effective in treating not only agitation but also delirium. I've seen multiple small RCTs to that effect.

Link(s)?

Sent from my SM-N910P using SDN mobile

 

[slappy]

Link(s)?

delirium antipsychotics duration - PubMed - NCBI

 

[WingedOx]

Now if only I could get med services to actually recognize delirium and not "new onset schizophrenia" or whatever...

 

[NickNaylor]

Heard a lecture from a noon conference via YouTube on treating delirium in medical inpatients. It was given by a psychiatrist. He basically said that anti-psychotics shouldn't be given, and that there is no real pharmacologic treatment that should be ordered in most cases. (Granted I was driving in a car with 2 noisy kids and listening on headphones so perhaps I misheard some of the nuance).

His reasoning was that the evidentiary basis is very low and the society for critical care medicine doesn't recommend Haldol for delirium. I'm confused about this and wanted some perspectives from psychiatrists on how to treat both hypoactive and hyperactive delirium of the type you might be consulted about on Night float (on the medicine service).

Lecture was here in case anyone is interested - Delirium with Dr. Zachary Sager

Critical care folks seem to have a love affair with dexmedetomidine (Precedex) for delirium based on a series of studies which show promise. I also found this study which directly compared Precedex and haloperidol and found Precedex to be superior.

By the way, continuous haloperidol infusion? Never heard of that before...

 

[slappy]

Critical care folks seem to have a love affair with dexmedetomidine (Precedex) for delirium based on a series of studies which show promise. I also found this study which directly compared Precedex and haloperidol and found Precedex to be superior.

By the way, continuous haloperidol infusion? Never heard of that before...

Yep, if the patient is in the ICU, my first recommendation quite often is a Precedex drip.

 

[ExcaliburPrime1]

Haldol (or Risperidone) is recommended only for agitation in delirium. Most of your delirium will be the "inattentive" kind and antipsychotics are not recommended.

What is recommended is the "boring stuff" that works, which is to do a good work-up to find an underlying cause and treat it (e.g. pain, infection, electrolyte abnormalities, hearing/vision augmentation), minimize interruptions at night and have bright lights/sunshine during the day to promote best sleep possible under the circumstances, frequent reorientation, etc.