Psychiatry - October 2008 - (Page 33)

TABLE 3. Evidence for the use of typical antipsychotics in delirium STUDY TYPE OF EVIDENCE COMMENTS Molindone (Fernandez F, Levy JK) n=4 Case study Molindone safe and effective Loxapine versus olanzapine (Kreiger D, et al.) n=1 Case study Loxapine superior to olanzapine Loxapine versus thioridazine (Versiani M, et al.) n=40 (20 patients per group) Thiothixine verus haloperidol (Peterson LG, Bognar B) n=14 (8 and 6 patients respectively) Haloperidol, chlorpromazine, and lorazepam (Breitbart W, et al.) n=30 (11, 13, and 6 patients in each respective group) Haloperidol, olanzapine, and placebo (Hu X, Deng W, Yang H) n=175 (72, 74, and 29 patients in each respective group) KEY: RCT—randomized, controlled trial RCT Loxapine superior to thioridazine in one trial of a two-part study but equivalent in other part RCT Haloperidol superior to thiothixene RCT Only study selected by Cochrane Collaboration. Both haloperidol and chlorpromazine superior to lorazepam Haloperidol equivalent to olanzapine and both superior to placebo RCT Delirium Rating Scale and a marked reduction in the Memorial Delirium Assessment Scale.29,30 Two other studies of olanzapine at mean doses of 4.5mg per day to 8.2mg per day demonstrated comparable reductions in delirium when measured against haloperidol at mean doses of 4.5mg per day to 5.1mg per day on the Delirium Rating Scale and Memorial Delirium Assessment Scale. The peak response time of both groups was similar at nearly seven days. In addition, those on olanzapine had less extrapyramidal side effects and less sedation than the haloperidol group.31,32 Quetiapine, with its very low incidence of extrapyramidal side effects, should be an attractive choice for the delirious elderly patient if proven clinically efficacious. Two sets of case reports with two patients each demonstrated quetiapine to be safe and effective for the treatment of delirium at doses of 50 to 100mg per day within one week of initiation. One of these reports utilized the Delirium Rating Scale and Mini Mental Scale Examination as rating scales while the other used no rating scales.33,34 When compared to haloperidol, delirious patients on quetiapine showed similar improvements on the Delirium Rating Scale but quetiapine was better tolerated.35 Four open-label trials of between 12 and 22 patients using quetiapine at 25 to 200mg per day demonstrated the effectiveness of this agent in almost all patients after approximately seven days of treatment with much improved Delirium Rating Scales, Mini Mental Scale Examination scales, and Clinical Global Impression scales.36–39 The two latest additions to the antipsychotic armamentarium, ziprasidone and aripiprazole, have less information published regarding delirium. A case report of a delirious 34-year-old HIV-positive man with possible cryptococcal meningitis had to be abandoned due to cardiac side effects. Ziprasidone treatment, initiated at 20mg per day and then titrated up to 100mg per day, led to an improvement in the delirium as demonstrated by a significant reduction in the Delirium Rating Scale. Nonetheless, there is too little information to draw a definitive conclusion.40 A case report in the anesthesiology literature reported the successful use of ziprasidone for delirium. Ziprasidone was given intravenously at 20mg after a failed course of haloperidol and then tapered orally over the course of a week. The patient improved but there were no details given on the doses of the taper or if any rating scale was used to measure the delirium.41 Aripiprazole, the newest atypical antipsychotic, likewise, has evidence of its usefulness in the treatment of delirium with two case studies each having two patients given 15 to 30mg of the agent per day and utilizing the Delirium Rating Scale and Mini Mental Scale Examination as rating scales.42,43 A case series examining 14 patients with delirium of varying etiologies treated with 5 to 15mg of aripiprazole per day demonstrated the [OCTOBER] Psychiatry 2008 33

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Psychiatry - October 2008

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