Psychiatry - October 2008 - (Page 35)

efficacy of this agent in nearly all patients treated. The response time ranged from several days to two weeks and was gauged with the Delirium Rating Scale and Clinical Global Impressions Scale.44 The evidence for use of atypical antipsychotics in delirium is presented in Table 4. Despite the fact that antipsychotics are useful for the treatment of delirium, these medications are associated increased risk of mortality in elderly patients with dementia, a common comorbid condition. One recent study documents the risk of a serious adverse event, defined as an event leading to acute care hospital admission or death, to be 2.4 times more likely for patients on typical antipsychotics than placebo and 1.9 times more likely for patients on atypical antipsychotics than placebo.45 Nonpharmacological treatments for delirium also exist and should not be overlooked in treating this serious condition. It should be recognized, however, that nonpharmacological treatments are adjuncts to, not substitutes for, prompt pharmacological treatment for delirium. The patient should be provided a quiet environment free of excess stimulation and be reoriented frequently. While providing a safe environment for the recovering patient is crucial, the patient should not be either overly stimulated or actively ignored. At the most basic level, the room that the patient is placed in should be well lit, moderately furnished, and contain a clock and a calendar. Contact with family and staff is helpful. Providing extra supportive physical care, such as nutrition and fluid intake, may be necessary. The use of physical restraints should be limited for diagnostic testing, performing procedures, and patient or staff safety. Document carefully and frequently in the chart the use and rationale for employing physical restraints. the wards in any hospital. Several typical antipsychotics have been demonstrated to be effective but have the potential problems of extrapyramidal side effects and cardiac conduction delays. Atypical antipsychotics are effective for delirium and are associated with less extrapyramidal side effects. While there is little in the way of head to head trials of typical antipsychotics versus atypical antipsychotics for the treatment of delirium, those that do exist seem to suggest equivalence.46,47 Haloperidol continues to be the “gold standard” medication for the treatment of delirium, but atypical antipsychotics may supplant the typical antipsychotics due to their effective and safe management of this condition.48 Numerous studies support the assertion that risperidone, olanzapine, and quetiapine have the best data for the treatment of delirium among the atypical antipsychotics.49 6. 7. 8. 9. ACKNOWLEDGMENTS The author would like to thank Brandon Cox, BA, for his assistance with graphic artwork and technology. 10. REFERENCES 1. Pompei P, Foreman M, Rudberg MA, et al. Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc.1994;42(8):809–815. Gleason OC. Delirium. Am Fam Physician. 2003;67(5):1027–1034. Kaplan HI, Sadock BJ. Delirium, dementia, and amnestic and other cognitive disorders and mental disorders due to a general medical condition. In: Kaplan HI, Sadock BJ (eds). Synopsis of Psychiatry. Eighth Edition. Philadelphia, PA: Lippincott, Williams, and Wilkins, 1998:320–328. Schwartz TL, Masand PS. The role of atypical antipsychotics in the treatment of delirium. Psychosomatics. 2002;43(3):171–174. Jacobson S and Schreibman B: Behavioral and pharmacologic treatment of delirium. Am Fam Physician. 1997;56(8):2005–2012. 11. 2. 3. 12. 4. 13. 14. 5. SUMMARY Delirium is a common medical condition likely to be encountered on Wise MG and Trzepacz PT: Delirium (Confusional States). In: Wise MG and Rundell JR, eds. The American Psychiatric Press Textbook of Consultation-Liaison Psychiatry. Washington D.C. American Psychiatric Press Publishing, 2005: 257–272. Trzepacz PT , Meagher DJ. Delirium. In: Levensen JL (ed). Textbook of Psychosomatic Medicine. Washington, DC: American Psychiatric Publishing, Inc., 2005:91–130. Heckers S. Delirium. In: Stern TA, Herman JB (eds). The Massachusetts General Hospital Psychiatry Update and Board Preparation, Second Edition. New York, NY: McGraw-Hill Publishing Company, 2004:43–47. Trzepacz P (chair). Practice Guidelines for the Treatment of Patients With Delirium, in American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2002. Washington, DC: American Psychiatric Association, 2002:29–60. Devanand DP, Marder K, Michaels KS, et al. A randomized, placebocontrolled dose-comparison trial of haloperidol for psychosis and disruptive behaviors in Alzheimer’s disease. Am J Psychiatry. 1998;155(11):1512–1520. Breitbart W, Marotta R, Platt M, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium of hospitalized AIDS patients. Am J Psychiatry. 1996;153(2):231–237. Hu X, Deng W, Yang H. A prospective random control study compraison of olanzapine and haloperidol in senile delirium [Chinese]. Chong’qing Med J. 2004;8:1234–1237. Pae C, Marks DM, Han C, et al. Delirium: where do we stand? Curr Psychiatry Rep. 2008;10;240–248. Peterson LG, Bongar B. Navane versus haldol: treatment of acute mental syndromes in the general hospital. Gen Hosp Psychiatry. 1989;11(6):412–417. [OCTOBER] Psychiatry 2008 35

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Psychiatry - October 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Treatment of Migraine and the Role of Psychiatric Medications Play Therapy: A Case-based Example of a Nondirective Approach Delirium and Antipsychotics: A Systematic Review of Epidemiologyand Somatic Treatment Options Severely Mood-disordered Youth Respond Less Well to Treatment in a Community Clinic than Youth with Bipolar Disorder Beyond Informed Consent: The Ethics of Informing, Anticipating, and Warning Asthma: Wheezing, Woes, and Worries Classified Advertising Journal Watch Information for Authors

Psychiatry - October 2008

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