Published in the March 2005 issue of Today’s Hospitalist
A potentially life-threatening condition that afflicts a significant number of inpatients can be a source of confusion “and controversy “when it comes to treatment. Delirium, whether it is the product of an underlying medical condition, ICU psychosis, or the drugs prescribed by another physician, is an emergent situation that experts say needs to be addressed more thoroughly “and in a more timely fashion.
“Delirium is a medical emergency, and it’s underrecognized,” says James Rudolph, MD, a geriatrician at Brigham and Women’s Hospital in Boston and instructor of medicine at Harvard School of Medicine. “The point to remember is that the delirious patient has an up to 10 times greater risk of dying in the hospital and a five times higher risk of infection than the patient who doesn’t have delirium.”
According to an often-quoted study by Inouye in a 1994 issue of the American Journal of Medicine, a large patient population faces a 56 percent higher risk of delirium. That high-risk group includes elderly patients, as well as patients of any age who have undergone surgery, are sensory deprived, or have suffered cardiac, renal or hepatic failure.
While the condition occurs in 10 percent to 18 percent of medical and surgical inpatients, it often goes unrecognized because physicians tend to focus primarily on the delirious patients who are agitated. As a result, Dr. Rudolph maintains, physicians may miss individuals with so-called “quiet” delirium.
“Those patients “individuals with hypoactive delirium ” are the ones my fellow internists sometimes miss, yet they account for 50 percent of delirious patients,” he says. “But the same risks and principles apply, and the outcomes for those [hypoactive] patients can be even worse” than for the hyperactive, violent delirious patient that he says hospitalists “won’t miss.”
How can you spot these hypoactive patients? They may be the individuals who are asleep at 7 a.m. when you first hit the wards and still asleep at 3 p.m., Dr. Rudolph explains, or they may be the patients who missed physical therapy or didn’t eat their lunch. He suggests evaluating any patient who isn’t engaging in daily activities or who appears to be oversleeping for possible delirium.
Geriatricians and psychiatrists who specialize in treating elderly inpatients stress the importance of preventing delirium whenever possible. When the condition has been diagnosed, they say, the first step is to identify and treat the underlying medical causes or the prescription drug that helped cause delirium. (See “Concerned about delirium? Watch what you prescribe in the elderly” below for more on prescription drugs that can cause delirium.)
“If you don’t get at the underlying cause,” Dr. Rudolph says, “you’re not going to clear up the delirium. That’s the reality of the situation.”
To treat or not to treat
Once you’ve diagnosed delirium in a patient, treating it correctly often requires fairly complex decision-making, according to Thomas Schwartz, MD, a delirium expert and psychiatrist who teaches at SUNY Upstate Medical University in Syracuse, N.Y.
The first decision is whether to use medication or physical restraints, or to simply use reorientation strategies while you treat the medical condition that is causing the delirium.
“That’s the biggest decision,” Dr. Schwartz says, “whether to do nothing and treat the medical condition through the usual manner, or to use chemical or physical restraints. And that decision usually has to do with how dangerous the patient is, either to himself or others.”
“If the patient is psychotic or agitated “someone who is pulling out her catheter or who thinks that the hospitalist is entering the room to steal her purse “she is probably a candidate for some type of restraint in order to reduce potential injury,” Dr. Schwartz adds.
“I really think that the chemical restraints are better than the physical,” Dr. Schwartz explains. “You need to calm people down and treat their psychosis, their thought disorder and their agitation with antipsychotics. ”
He notes, however, that patients who are fl ailing and endangering themselves or staff may require a combination of physical and chemical restraints.
Two schools of thought
One of the big issues for hospitalists “and one that is often a source of confusion “is what to prescribe in the form of chemical restraints. Dr. Schwartz points to two schools of thought on the subject.
The first says that a mild case of delirium is best addressed by doing nothing other than treating the medical conditions that caused it. The other says that delirium should be treated pharmacologically in hope of shortening its course.
If you elect to follow the latter course, the choice of drug and drug class, dosage, and treatment schedule and duration are decisions that should be based on the severity of the delirium and, perhaps more important, the potential risks associated with drug treatment.
Your basic choices are the older antipsychotic haloperidol or the newer second-generation antipsychotics. While Dr. Schwartz notes that the longtime standard, haloperidol, is increasingly being abandoned in favor of the newer atypical antipsychotics, he says that second-generation drugs like risperidone, olanzapine, quetiapine and ziprasidone may not always be the better choice.
It’s true that those newer drugs, which produce a serotonergic blockade, are associated with a better side effect profile in some areas. Perhaps most notably, they offer a lower incidence of tremor, spasm and restlessness, and fewer extrapyramidal effects than haloperidol.
The problem? There are scant data on their use in patients who don’t have delirium.
“Typically for patients with schizophrenia, these newer antipsychotics are safer, but some of them can make patients sedated or dizzy,” Dr. Schwartz says. “It’s a different side effect profile that might be worse for the medically ill patient, and we do not want to give the delirious patient more symptoms.”
(Dr. Schwartz was lead author of a review study in the June 2002 issue of Psychosomatics that is viewed by many experts as an authoritative guide on the topic of using atypical antipsychotics to treat delirium.)
For example, Dr. Schwartz says, “The extra sedation associated with some second-generation antipsychotics might mask a worsening of medical symptoms in some patients. It could also exacerbate problems in patients who have dizziness or fainting problems already.”
In addition, Dr. Schwartz notes, recent studies have shown an association between some newer antipsychotics and a slightly higher risk of stroke when used in elderly patients with dementia.
The tried-and-true approach
That’s why he says that if you are concerned about the potential side effects in high-risk patients or you’re unfamiliar with atypical antipsychotics, take the tried-and-true approach: haloperidol.
“It’s still the gold standard and it’s one of the cleanest, safest medications we have,” he explains, “because it does not disrupt heart rate and blood pressure.” In addition, haloperidol can be delivered by either IV drip or intramuscularly, which gives it an advantage over some newer drugs that can only be taken orally.
“If you’re a conservative clinician and you like rules and data and the best support,” Dr. Schwartz says, “stick with the haloperidol-based guidelines. You’ll never be faulted from a medical-legal sense.”
And if your patient can’t tolerate haloperidol, he says, follow the lead of the most recent (1999) guidelines from the American Psychiatric Association for treating delirium. Dr. Schwartz suggests switching patients who can’t tolerate haloperidol or who exhibit neuromuscular side effects to an atypical antipsychotic, but he cautions that these patients should be closely watched.
While Dr. Rudolph more or less concurs with Dr. Schwartz’ perspective on choosing drugs, he tends to lean toward the newer antipsychotics. “My impression is that the new atypical antipsychotics do have slightly better side effect profiles and a lower incidence of extrapyramidal issues such as pharyngeal dysfunction,” he says.
While Dr. Rudolph acknowledges that there are few studies supporting this view, he predicts those data aren’t going to be forthcoming. “It’s hard to get consent [to study a patient] when someone is kicking, screaming and throwing things,” he says.
Helen Lavretsky, MD, a geriatric psychiatrist at UCLA’s Neuropsychiatric Institute in Los Angeles, agrees about the importance of addressing underlying medical causes ” electrolyte imbalances or infections in particular “before moving to pharmaceuticals. She also stresses the importance, in suspected ICU psychosis, of reorienting the patient and attempting to stabilize the sleeping pattern by moving patients to a dark room before prescribing either haloperidol or second-generation antipsychotics.
“Unless those things are done, even pharmacological treatment of delirium might not be sufficient,” Dr. Lavretsky warns. “It has to be combined with behavioral or environmental modifications.”
If antipsychotics are warranted, however, she agrees that haloperidol, not atypical antipsychotics, should be your first-line treatment for patients with concomitant psychosis and delirium. She starts with small doses (0.5 mg) every four to six hours. “It’s shorter acting than risperidone,” Dr. Lavretsky explains, “and it can be given intravenously.”
Dosing is another major issue with delirium that experts say is poorly understood. The physicians interviewed for this story say that’s especially true because the emergence of the atypical antipsychotics has significantly expanded the range of therapeutic options.
The key with either haloperidol or second-generation drugs, however, is that you need much lower doses to treat delirium than you would prescribe to treat schizophrenia or bipolar disorder. “It’s half or less of the usual dosing,” Dr. Schwartz explains. If the risperidone package insert calls for a 1.0 mg starting dose, for example, you might start with 0.5 mg.
Based on his institution’s experience with both generations of antipsychotics, Dr. Rudolph thinks that even lower doses can be both safe and effective. With haloperidol, his first-line choice for very agitated or dangerous delirious patients, or those who can’t or won’t take oral medication, he recommends starting with very low doses.
“I recommend extremely low doses “0.25 to 0.5 mg,” Dr. Rudolph says. “And if that gets them calm, you can switch to an atypical antipsychotic.” He adds that there is still a tendency, especially in the emergency department, to use far higher doses than necessary.
When he’s prescribing risperidone, Dr. Rudolph recommends starting with 0.25 mg. When prescribing olanzapine, he suggests starting with 2.5 mg. With quetiapine, he recommends an initial dosing of 25 mg.
Dr. Rudolph also stresses the importance of scheduled dosing as opposed to as-needed dosing, an approach he thinks is not used often enough. He recommends giving a morning dose and an afternoon dose at regular times.
“If you give the second dose at 3 p.m., before the patient starts to sundown, that will cover them until you give another morning dose,” he explains. “The point is to prevent the psychotic breakdown before it happens.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.
Concerned about delirium? Watch what you prescribe in the elderly
One of the ironies of delirium is that while the condition can be devastating, it can be relatively easy to prevent, particularly in elderly patients who fare the worst. And a prime place to start is inappropriate prescription drugs.
James Rudolph, MD, a geriatrician at Brigham and Women’s Hospital in Boston and instructor of medicine at Harvard Medical School, says that the “major offenders” that can cause delirium in the elderly include pain medications such as meperidine (Demerol), benzopdiazepines such as diazepam (Valium) and chlordiazepoxide (Librium), and anticholinergic drugs such as Benadryl. He adds that antispasmodics, including agents used to treat incontinence, can also cause or worsen delirium in elderly patients.
While many of these drugs are prescribed by outpatient physicians, Dr. Rudolph says, some physicians who work only in the inpatient setting might unwittingly elect a prescribing course that causes or worsens delirium down the road, in part because they don’t see the sequellae months later.
“The knowledge is there,” he says, “but sometimes connecting all the arrows to all the points is absent. And those of us who work in hospitals tend to say, ‘They have incontinence, give them this drug.’ But you need to take a step back and say, ‘Wait a second. If I give this drug for incontinence, it might cause more problems because it blocks the cholinergic receptors.’ ” That path, Dr. Rudolph adds, can cause or worsen dementia.
Benzodiazepines are also problematic because they have an extraordinarily long half-life in the elderly “up to 100 hours in the case of Valium. “They remain in the body forever,” Dr. Rudolph says, “but so many people are taking Valium that doctors just kind of forget sometimes.” He emphasizes that the medication is a poor choice in elderly patients.