LONG BEACH, CALIF. — So little is known about effective interventions for delirium that efforts to help elderly patients with the condition leave many providers, well, delirious.
The goal of treating delirium is not just to control agitation or hallucinations, but to reverse the delirium and thereby mitigate associated morbidity and mortality risks, Dr. Jay S. Luxenberg said at the annual meeting of the California Association of Long Term Care Medicine.
“The modern concepts of delirium emphasize that delirium can be a persistent issue for a given patient, persisting months and even years,” said Dr. Luxenberg, an internist and geriatrician who is medical director of the Jewish Home in San Francisco. “It may actually reflect a current decline in cognitive functions.”
Another emerging concept about delirium is that it markedly and independently affects patient outcomes such as length of stay, functional decline, and loss of independent living.
“What we need to be thinking of is baseline vulnerability to delirium: what pushes people over the edge,” said Dr. Luxenberg, also of the University of California, San Francisco. “Ultimately, the precipitating factor is just that: the precipitating factor. Of course if they have a urinary tract infection, we're going to treat it. If they have bronchitis, we're going to treat it.”
The exact incidence of delirium among the elderly is not known, but Dr. Luxenberg said that it is surely higher than the national average of 2% reported by Medicare for the period of July 1, 2006, through Dec. 31, 2006. “It isn't being identified as clearly as it should be,” he asserted.
He recommended being specific about delirium symptoms of risk factors during admission assessments (see sidebar). “On your problem list, identify things explicitly because the people who do the [Minimum Data Set] look for written data from the doctor,” he said. “Anytime a patient is on a lot of medications we should list polypharmacy as one of their problems, even if they need every one of those drugs. Similarly, if the person has delirium, we should write it, not imply it.”
In a study of 2,158 patients with an average age of 84, admitted to a skilled nursing facility from a hospital, 16% had delirium as defined by the Confusion Assessment Method (J. Gerontol. A Biol. Sci. Med. Sci. 2003;58:M441–5). In addition, about 13% of patients had two or more symptoms of delirium and about 40% had one symptom of delirium.
Unresolved, delirium can have significant impact on mortality. One study of 393 postacute care patients (with an average age of 84 years) found that functional recovery differed significantly by delirium resolution status (J. Gerontol. A Biol. Sci. Med. Sci. 2006;61:204–8). Specifically, patients who resolved their delirium within 2 weeks without recurrence regained 100% of their prehospital functional level, while those who did not retained less than 50% of their prehospital functional level.
In a more recent study, researchers used the Memorial Delirium Assessment Scale to assess psychomotor activity in 457 newly admitted delirious postacute care patients (J. Gerontol. A Biol. Sci. Med. Sci. 2007;62:174–9). The patients were classified as hyperactive, hypoactive, mixed, or normal.
Hypoactive patients were 1.6 times more likely to die during 1 year of follow-up compared with patients who had normal psychomotor activity, a difference that was statistically significant. Patients with the hyperactive and mixed subtypes had an increased risk of dying during 1 year of follow-up compared with patients who had normal psychomotor activity, but the elevations were not statistically significant.
The current data on treatment options for delirium “makes you yearn for more data and better studies,” he said.
A Cochrane review that Dr. Luxenberg helped assemble on the use of antipsychotics for delirium found only three studies suitable for inclusion (Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005594. DOI:10.1002/14651858.CD005594.pub2.) Meta-analysis was only possible in comparing risperidone vs. haloperidol and olanzapine vs. haloperidol. The results showed no significant difference in overall effect on delirium with olanzapine or risperidone compared with haloperidol.
Data on the use of cholinesterase inhibitors and benzodiazepines for delirium are even more sparse.
One controlled study of haloperidol as a delirium prophylaxis in hip surgery patients found that while there was no effect on the postoperative incidence of acute confusion, patients in the haloperidol arm had earlier improvement of delirium scores and had less severe delirium compared with patients who did not take the drug. The average age of study participants was 79 years (J. Am. Geriatr. Soc. 2005;53:1658–66).
“Somebody should do this study again,” Dr. Luxenberg said. “This is potentially interesting.”