Top

Published in:

01-09-2011 | Review Article

Identification and Management of In-Hospital Drug-Induced Delirium in Older Patients

Author: Dr Angela G. Catic

Published in: Drugs & Aging | Issue 9/2011

Abstract

Delirium, an acute confusional state with changes in attention and cognition, is a common cause of morbidity and mortality among hospitalized elders. Medications are responsible for up to 39% of delirium cases in the elderly. The incidence of drug-induced delirium is particularly high in this population due to the altered pharmacokinetics and pharmacodynamics of aging, high prevalence of polypharmacy and occurrence of co-morbid disease. Although certain medications are more often associated with the development of delirium, including opioids, benzodiazepines, anticholinergics and antidepressants, any medication can cause delirium in the elderly. Evaluation of delirium should include a thorough medication history, which should determine if any new medications have been initiated, if medications have been discontinued, and the details of any recent dosage adjustments.

It is important to understand the utility of medications in preventing and treating delirium in the elderly. Acetylcholinesterase inhibitors have not been found to reduce the incidence of delirium or length of hospitalization. Study results regarding the utility of antipsychotic medications in preventing delirium have been mixed. Haloperidol prophylaxis did not reduce the occurrence of delirium, but it did reduce the severity and duration. Olanzapine and risperidone were associated with a reduced incidence of delirium compared with placebo.

Pharmacological therapy to treat delirium should be implemented only if patients pose a safety risk to themselves or others. Typical and atypical antipsychotics are effective in treating the symptoms of delirium, but it is important to note that they are not approved by the US FDA for this indication. Short-acting benzodiazepines are second-line therapy and are typically reserved for patients with sedative/alcohol withdrawal, Parkinson’s disease or neuroleptic malignant syndrome. Study results regarding the utility of acetylcholinesterase inhibitors have been mixed.

Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing 2006 Jul; 35(4): 350–64PubMedCrossRef

McCusker J, Cole M, Abrahamowicz M, et al. Delirium predicts 12-month mortality. Arch Intern Med 2002 Feb 25; 162(4): 457–63PubMedCrossRef

Inouye SK. Delirium in older persons. N Engl J Med 2006 Mar 16; 354(11): 1157–65PubMedCrossRef

Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons: predictive model and interrelationship with baseline vulnerability. JAMA 1996 Mar 20; 275(11): 852–7PubMedCrossRef

Laurila JV, Laakkonen ML, Tilvis RS, et al. Predisposing and precipitating factors for delirium in a frail geriatric population. J Psychosom Res 2008 Sep; 65(3): 249–54PubMedCrossRef

Diagnostic and statistical manual of mental disorders. Rev. 4th ed. Washington, DC: American Psychiatric Association, 2000

Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990 Dec 15; 113(12): 941–8PubMed

Iglseder B, Dovjak P, Benvenuti-Falger U, et al. Drug-related delirium in elderly patients [in German]. Wien Med Wochenschr 2010 Jun; 160(11–12): 281–5PubMedCrossRef

Alagiakrishnan K, Wiens CA. An approach to drug induced delirium in the elderly. Postgrad Med J 2004 Jul; 80(945): 388–93PubMedCrossRef

10.

Rudberg MA, Pompei P, Foreman MD, et al. The natural history of delirium in older hospitalized patients: a syndrome of heterogeneity. Age Ageing 1997 May; 26(3): 169–74PubMedCrossRef

11.

Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994 Sep; 97(3): 278–88PubMedCrossRef

12.

Schwartz JB. The current state of knowledge on age, sex, and their interactions on clinical pharmacology. Clin Pharmacol Ther 2007 Jul; 82(1): 87–96PubMedCrossRef

13.

Maletta GJ. Pharmacotherapy in the elderly. In: Agronin ME, Maletta GJ, editors. Principles and practice of geriatric psychiatry. Philadelphia (PA): Lippincott Williams & Wilkins, 2006: 199–220

14.

Hajjar ER, Hanlon JT, Artz MB, et al. Adverse drug reaction risk factors in older outpatients. Am J Geriatr Pharmacother 2003 Dec; 1(2): 82–9PubMedCrossRef

15.

Hanlon JT, Pieper CF, Hajjar ER, et al. Incidence and predictors of all and preventable adverse drug reactions in frail elderly persons after hospital stay. J Gerontol A Biol Sci Med Sci 2006 May; 61(5): 511–5PubMedCrossRef

16.

Bressler R, Bahl JJ. Principles of drug therapy for the elderly patient. Mayo Clin Proc 2003 Dec; 78(12): 1564–77PubMedCrossRef

17.

Burkhardt H, Gladisch R. Pharmacotherapy of elderly patients from the clinical viewpoint [in German]. Internist (Berl) 2003 Aug; 44(8): 959–67CrossRef

18.

Alexander E. Delirium in the intensive care unit: medications as risk factors. Crit Care Nurse 2009 Feb; 29(1): 85–7PubMedCrossRef

19.

Clegg A, Young JB. Which medications to avoid in people at risk of delirium: a systematic review. Age Ageing 2011 Jan; 40(1): 23–9PubMedCrossRef

20.

Crombez G, Eccleston C, Baeyens F, et al. The disruptive nature of pain: an experimental investigation. Behav Res Ther 1996 Nov-Dec; 34(11–12): 911–8PubMedCrossRef

21.

Crombez G, Eccleston C, Baeyens F, et al. Habituation and the interference of pain with task performance. Pain 1997 Apr; 70(2–3): 149–54PubMedCrossRef

22.

Eccleston C. Chronic pain and distraction: an experimental investigation into the role of sustained and shifting attention in the processing of chronic persistent pain. Behav Res Ther 1995 May; 33(4): 391–405PubMedCrossRef

23.

Marcantonio ER, Flacker JM, Wright RJ, et al. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 2001 May; 49(5): 516–22PubMedCrossRef

24.

Milisen K, Foreman MD, Abraham IL, et al. A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients. J Am Geriatr Soc 2001 May; 49(5): 523–32PubMedCrossRef

25.

Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003 Jan; 58(1): 76–81PubMedCrossRef

26.

Potter JF. The older orthopaedic patient: general considerations. Clin Orthop Relat Res 2004 Aug; (425): 44–9

27.

Fong HK, Sands LP, Leung JM. The role of postoperative analgesia in delirium and cognitive decline in elderly patients: a systematic review. Anesth Analg 2006 Apr; 102(4): 1255–66PubMedCrossRef

28.

Ersek M, Cherrier MM, Overman SS, et al. The cognitive effects of opioids. Pain Manag Nurs 2004 Jun; 5(2): 75–93PubMedCrossRef

29.

Vaurio LE, Sands LP, Wang Y, et al. Postoperative delirium: the importance of pain and pain management. Anesth Analg 2006 Apr; 102(4): 1267–73PubMedCrossRef

30.

Egbert AM, Parks LH, Short LM, et al. Randomized trial of postoperative patient-controlled analgesia vs intramuscular narcotics in frail elderly men. Arch Intern Med 1990 Sep; 150(9): 1897–903PubMedCrossRef

31.

Marcantonio ER, Juarez G, Goldman L, et al. The relationship of postoperative delirium with psychoactive medications. JAMA 1994 Nov 16; 272(19): 1518–22PubMedCrossRef

32.

Foy A, O’Connell D, Henry D, et al. Benzodiazepine use as a cause of cognitive impairment in elderly hospital in-patients. J Gerontol A Biol Sci Med Sci 1995 Mar; 50(2): M99–106PubMedCrossRef

33.

Pisani MA, Murphy TE, Araujo KL, et al. Benzodiazepine and opioid use and the duration of intensive care unit delirium in an older population. Crit Care Med 2009 Jan; 37(1): 177–83PubMedCrossRef

34.

Tune L, Carr S, Hoag E, et al. Anticholinergic effects of drugs commonly prescribed for the elderly: potential means for assessing risk of delirium. Am J Psychiatry 1992 Oct; 149(10): 1393–4PubMed

35.

Mintzer J, Burns A. Anticholinergic side-effects of drugs in elderly people. J R Soc Med 2000 Sep; 93(9): 457–62PubMed

36.

Feinberg M. The problems of anticholinergic adverse effects in older patients. Drugs Aging 1993 Jul-Aug; 3(4): 335–48PubMedCrossRef

37.

Rudolph JL, Salow MJ, Angelini MC, et al. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med 2008 Mar 10; 168(5): 508–13PubMedCrossRef

38.

Campbell N, Boustani M, Limbil T, et al. The cognitive impact of anticholinergics: a clinical review. Clin Interv Aging 2009; 4: 225–33PubMed

39.

Han L, McCusker J, Cole M, et al. Use of medications with anticholinergic effect predicts clinical severity of delirium symptoms in older medical inpatients. Arch Intern Med 2001 Apr 23; 161(8): 1099–105PubMedCrossRef

40.

Blum D, Maldonado J, Meyer E, et al. Delirium following abrupt discontinuation of fluoxetine. Clin Neurol Neurosurg 2008 Jan; 110(1): 69–70PubMedCrossRef

41.

Liptzin B, Laki A, Garb JL, et al. Donepezil in the prevention and treatment of post-surgical delirium. Am J Geriatr Psychiatry 2005 Dec; 13(12): 1100–6PubMed

42.

Sampson EL, Raven PR, Ndhlovu PN, et al. A randomized, double-blind, placebo-controlled trial of donepezil hydrochloride (Aricept) for reducing the incidence of postoperative delirium after elective total hip replacement. Int J Geriatr Psychiatry 2007 Apr; 22(4): 343–9PubMedCrossRef

43.

Gamberini M, Bolliger D, Lurati Buse GA, et al. Rivastigmine for the prevention of postoperative delirium in elderly patients undergoing elective cardiac surgery: a randomized controlled trial. Crit Care Med 2009 May; 37(5): 1762–8PubMedCrossRef

44.

Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001 Jul; 29(7): 1370–9PubMedCrossRef

45.

Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 2005 Oct; 53(10): 1658–66PubMedCrossRef

46.

Trzepacz PT, Mittal D, Torres R, et al. Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium. J Neuropsychiatry Clin Neurosci 2001 Spring; 13(2): 229–42PubMedCrossRef

47.

Schrader SL, Wellik KE, Demaerschalk BM, et al. Adjunctive haloperidol prophylaxis reduces postoperative delirium severity and duration in at-risk elderly patients. Neurologist 2008 Mar; 14(2): 134–7PubMedCrossRef

48.

Larsen KA, Kelly SE, Stern TA, et al. Administration of olanzapine to prevent postoperative delirium in elderly joint-replacement patients: a randomized, controlled trial. Psychosomatics 2010 Sep-Oct; 51(5): 409–18PubMed

49.

Prakanrattana U, Prapaitrakool S. Efficacy of risperidone for prevention of postoperative delirium in cardiac surgery. Anaesth Intensive Care 2007 Oct; 35(5): 714–9PubMed

50.

Breitbart W, Marotta R, Platt MM, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry 1996 Feb; 153(2): 231–7PubMed

51.

Han CS, Kim YK. A double-blind trial of risperidone and haloperidol for the treatment of delirium. Psychosomatics 2004 Jul-Aug; 45(4): 297–301PubMedCrossRef

52.

Skrobik YK, Bergeron N, Dumont M, et al. Olanzapine vs haloperidol: treating delirium in a critical care setting. Intensive Care Med 2004 Mar; 30(3): 444–9PubMedCrossRef

53.

Girard TD, Pandharipande PP, Carson SS, et al. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: the MIND randomized, placebo-controlled trial. Crit Care Med Feb 2010; 38(2): 428–37CrossRef

54.

Ozbolt LB, Paniagua MA, Kaiser RM. Atypical antipsychotics for the treatment of delirious elders. J Am Med Dir Assoc 2008 Jan; 9(1): 18–28PubMedCrossRef

55.

Kim SW, Yoo JA, Lee SY, et al. Risperidone versus olanzapine for the treatment of delirium. Hum Psychopharmacol 2010 Jun; 25(4): 298–302PubMedCrossRef

56.

Devlin JW, Roberts RJ, Fong JJ, et al. Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study. Crit Care Med 2010 Feb; 38(2): 419–27PubMedCrossRef

57.

Wang PS, Schneeweiss S, Avorn J, et al. Risk of death in elderly users of conventional vs. atypical antipsychotic medications. N Engl J Med 2005 Dec 1; 353(22): 2335–41PubMedCrossRef

58.

Gill SS, Bronskill SE, Normand SL, et al. Antipsychotic drug use and mortality in older adults with dementia. Ann Intern Med 2007 Jun 5; 146(11): 775–86PubMed

59.

Schneeweiss S, Setoguchi S, Brookhart A, et al. Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients. CMAJ 2007 Feb 27; 176(5): 627–32PubMedCrossRef

60.

Setoguchi S, Wang PS, Alan Brookhart M, et al. Potential causes of higher mortality in elderly users of conventional and atypical antipsychotic medications. J Am Geriatr Soc 2008 Sep; 56(9): 1644–50PubMedCrossRef

61.

Dorsey ER, Rabbani A, Gallagher SA, et al. Impact of FDA black box advisory on antipsychotic medication use. Arch Intern Med 2010 Jan 11; 170(1): 96–103PubMedCrossRef

62.

Oldenbeuving AW, de Kort PL, Jansen BP, et al. A pilot study of rivastigmine in the treatment of delirium after stroke: a safe alternative. BMC Neurol 2008; 8: 34PubMedCrossRef

63.

Trzepacz PT, Baker RW, Greenhouse J. A symptom rating scale for delirium. Psychiatry Res 1988 Jan; 23(1): 89–97PubMedCrossRef

64.

van Eijk MM, Roes KC, Honing ML, et al. Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: a multicentre, double-blind, placebo-controlled randomised trial. Lancet 2010 Nov 27; 376(9755): 1829–37PubMedCrossRef

65.

Inouye SK, Rushing JT, Foreman MD, et al. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med 1998 Apr; 13(4): 234–42PubMedCrossRef

66.

Witlox J, Eurelings LS, de Jonghe JF, et al. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA 2010 Jul 28; 304(4): 443–51PubMedCrossRef

67.

Koster S, Hensens AG, van der Palen J. The long-term cognitive and functional outcomes of postoperative delirium after cardiac surgery. Ann Thorac Surg 2009 May; 87(5): 1469–74PubMedCrossRef

68.

McCusker J, Cole M, Dendukuri N, et al. Delirium in older medical inpatients and subsequent cognitive and functional status: a prospective study. CMAJ 2001 Sep 4; 165(5): 575–83PubMed

69.

McAvay GJ, Van Ness PH, Bogardus Jr ST, et al. Older adults discharged from the hospital with delirium: 1-year outcomes. J Am Geriatr Soc 2006 Aug; 54(8): 1245–50PubMedCrossRef

70.

Pisani MA, Kong SY, Kasl SV, et al. Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med 2009 Dec 1; 180(11): 1092–7PubMedCrossRef

Title: Identification and Management of In-Hospital Drug-Induced Delirium in Older Patients
Author: Dr Angela G. Catic
Publication date: 01-09-2011
Publisher: Springer International Publishing
Published in: Drugs & Aging / Issue 9/2011
Print ISSN: 1170-229X
Electronic ISSN: 1179-1969
DOI: https://doi.org/10.2165/11592240-000000000-00000

ACC 2024 Congress Coverage

Heart Failure Video

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Identification and Management of In-Hospital Drug-Induced Delirium in Older Patients

Abstract

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 9/2011

Low-Dose Pravastatin and Age-Related Differences in Risk Factors for Cardiovascular Disease in Hypercholesterolaemic Japanese

Physician Differences in Managing Postmenopausal Osteoporosis

Special Considerations with the Use of Intravenous Immunoglobulin in Older Persons

Pattern of Use of β-Blockers in Older Patients with Stable Coronary Artery Disease

Optimal Pharmacotherapeutic Management of Acute Lymphoblastic Leukaemia in the Elderly

5% Lidocaine Medicated Plaster in Elderly Patients with Postherpetic Neuralgia

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page