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Atypical antipsychotics in the management of delirium: A review of the empirical literature

Published online by Cambridge University Press:  03 March 2006

SOENKE BOETTGER  and
WILLIAM BREITBART
SOENKE BOETTGER
Affiliation:
Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, Box 421, New York, New York 10021, USA
WILLIAM BREITBART
Affiliation:
Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, Box 421, New York, New York 10021, USA
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Abstract

Objectives: To review the existing literature of atypical antipsychotics in the treatment of delirium and make recommendations regarding their use in the treatment of delirium.

Methods: I conducted a literature search in Pubmed, Psychlit, and Embase for studies using atypical antipsychotics in the treatment of delirium. In the absence of studies, case reports were used.

Results: Overall 13 studies examined the use of risperidone, olanzapine, and quetiapine, two cases were reported about ziprasidone, and no publication was found using aripiprazole in the treatment of delirium. Among the existing studies were retrospective and prospective, open label studies in addition to one with a double blind design using risperidone. Risperidone, olanzapine, and quetiapine may be all similarly effective in the treatment of delirium, whereas there may be limited efficacy in the use of olanzapine in the hypoactive subtype of delirium in elderly populations, which may generalize to the other atypical antipsychotics. The use of atypical antipsychotics in the treatment of delirium is safe and carries a low burden of side effects.

Significance of results: Although atypical antipsychotics are widely used in the treatment of delirium, well-designed studies do not exist. Among the existing studies, stronger data supports the use of risperidone and olanzapine, and also quetiapine may be considered in the treatment of delirium. Recommendations are made based on the existing data and literature. The need for well-designed studies to validate the use of atypical antipsychotics in the treatment of delirium continues.

Keywords

DeliriumTreatmentReviewAtypical Antipsychotics

Information

Type
REVIEW ARTICLE
Information
Palliative & Supportive Care , Volume 3 , Issue 3 , September 2005 , pp. 227 - 237
Copyright
© 2005 Cambridge University Press

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References

REFERENCES

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association.
Ananth, J., Parameswaran, S., & Gunatilake, S. (2004). Side effects of atypical antipsychotic drugs. Current Pharmaceutical Design, 10, 2219–2229.Google Scholar
Borison, R.L. & Diamond, B.I. (1983). Regional selectivity of neuroleptic drugs: An argument for site specificity. Brain Research Bulletin, 11, 215–218.Google Scholar
Breitbart, W., Marotta, R., Platt, M.M., et al. (1996). A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. American Journal of Psychiatry, 153, 231–237.Google Scholar
Breitbart, W., Rosenfeld, B., Roth, A., et al. (1997). The Memorial Delirium Assessment Scale. Journal of Pain and Symptom Management, 13, 128–137.Google Scholar
Breitbart, W. & Strout, D. (2000). Delirium in the terminally ill. Clinics in Geriatric Medicine, 16, 357–372.Google Scholar
Breitbart, W., Tremblay, A., & Gibson, C. (2002). An open trial of olanzapine for the treatment of delirium in hospitalized cancer patients. Psychosomatics, 43, 175–182.Google Scholar
Bucht, G., Gustafson, Y., & Sandberg, O. (1999). Epidemiology of delirium. Dementia and Geriatric Cognitive Disorders, 10, 315–318.Google Scholar
Cole, M., McCusker, J., Dendukuri, N., et al. (2003). The prognostic significance of subsyndromal delirium in elderly medical inpatients. Journal of the American Geriatric Society, 51, 754–760.Google Scholar
Conn, D.K. & Lieff, S. (2001). Diagnosing and managing delirium in the elderly. Canadian Family Physician, 47, 101–108.Google Scholar
Doyle, M. & Warden, D. (1996). Use of SPECT to evaluate postcardiotomy delirium. American Journal of Psychiatry, 153, 838–839.Google Scholar
Ereshefsky, L. & Lacombe, S. (1993). Pharmacological profile of risperidone. Canadian Journal of Psychiatry, 38(Suppl. 3), S80–S88.Google Scholar
Factor, S.A. (2002). Pharmacology of atypical antipsychotics. Clinical Neuropharmacology, 25, 153–157.Google Scholar
Fischer, P. (2001). Successful treatment of nonanticholinergic delirium with a cholinesterase inhibitor. Journal of Clinical Psychopharmacology, 21, 118.Google Scholar
Fulton, B. & Goa, K.L. (1997). Olanzapine. A review of its pharmacological properties and therapeutic efficacy in the management of schizophrenia and related psychoses. Drugs, 53, 281–298.Google Scholar
Goren, J.L. & Levin, G.M. (1998). Quetiapine, an atypical antipsychotic. Pharmacotherapy, 18, 1183–1194.Google Scholar
Grant, S. & Fitton, A. (1994). Risperidone. A review of its pharmacology and therapeutic potential in the treatment of schizophrenia. Drugs, 48, 253–273.Google Scholar
Han, C.H. & Kim, Y.K. (2004). A double-blind trial of risperidone and haloperidol for the treatment of delirium. Psychosomatics, 45, 297–301.Google Scholar
Harrigan, E.P., Miceli, J.J., Anziano, R., et al. (2004). A randomized evaluation of the effects of six antipsychotic agents on QTc, in the absence and presence of metabolic inhibition. Journal of Clinical Psychopharmacology, 24, 62–69.Google Scholar
Herrmann, N., Mamdani, M., & Lanctot, K.L. (2004). Atypical antipsychotics and risk of cerebrovascular accidents. American Journal of Psychiatry, 161, 1113–1115.Google Scholar
Horikawa, N., Yamazaki, T., Miyamoto, K., et al. (2003). Treatment for delirium with risperidone: Results of a prospective open trial with 10 patients. General Hospital Psychiatry, 25, 289–292.Google Scholar
Ichikawa, J., Dai, J., O'Laughlin, I.A., et al. (2002a). Atypical, but not typical, antipsychotic drugs increase cortical acetylcholine release without an effect in the nucleus accumbens or striatum. Neuropsychopharmacology, 26, 325–339.Google Scholar
Ichikawa, J., Li, Z., Dai, J., et al. (2002b). Atypical antipsychotic drugs, quetiapine, iloperidone, and melperone, preferentially increase dopamine and acetylcholine release in rat medial prefrontal cortex: Role of 5-HT1A receptor agonism. Brain Research, 956, 349–357.Google Scholar
Inouye, S.K. (1998). Delirium in hospitalized older patients. Clinics in Geriatric Medicine, 14, 745–764.Google Scholar
Kapur, S. & Seeman, P. (2001). Does fast dissociation from the dopamine d(2) receptor explain the action of atypical antipsychotics? A new hypothesis. American Journal of Psychiatry, 158, 360–369.Google Scholar
Kennedy, J.S., Zagar, A., Bymaster, F., et al. (2001). The central cholinergic system profile of olanzapine compared with placebo in Alzheimer's disease. International Journal of Geriatric Psychiatry, 16(Suppl. 1), S24–S32.Google Scholar
Kim, J.Y., Jung, I.K., Han, C., et al. (2005). Antipsychotics and dopamine transporter gene polymorphisms in delirium patients. Psychiatry and Clinical Neurosciences, 59, 183–188.Google Scholar
Kim, K.S., Pae, C.U., Chae, J.H., et al. (2001). An open pilot trial of olanzapine for delirium in the Korean population. Psychiatry and Clinical Neurosciences, 55, 515–519.Google Scholar
Kim, K.Y., Bader, G.M., Kotlyar, V., et al. (2003). Treatment of delirium in older adults with quetiapine. Journal of Geriatric Psychiatry and Neurology, 16, 29–31.Google Scholar
Koponen, H.J. (1999). Neurochemistry and delirium. Dementia and Geriatric Cognitive Disorders, 10, 339–341.Google Scholar
Leso, L. & Schwartz, T.L. (2002). Ziprasidone treatment of delirium. Psychosomatics, 43, 61–62.Google Scholar
Lieberman, J.A., Mailman, R.B., Duncan, G., et al. (1998). Serotonergic basis of antipsychotic drug effects in schizophrenia. Biological Psychiatry, 44, 1099–1117.Google Scholar
Lipowski, Z.J. (1987). Delirium (acute confusional states). Journal of the American Medical Association, 258, 1789–1792.Google Scholar
Liu, C.Y., Juang, Y.Y., Liang, H.Y., et al. (2004). Efficacy of risperidone in treating the hyperactive symptoms of delirium. International Clinical Psychopharmacology, 19, 165–168.Google Scholar
Lockwood, A.H., Yap, E.W., Rhoades, H.M., et al. (1991). Altered cerebral blood flow and glucose metabolism in patients with liver disease and minimal encephalopathy. Journal of Cerebral Blood Flow and Metabolism, 11, 331–336.Google Scholar
Manos, P.J. & Wu, R. (1997). The duration of delirium in medical and postoperative patients referred for psychiatric consultation. Annals of Clinical Psychiatry, 9, 219–226.Google Scholar
Massie, M.J., Holland, J., & Glass, E. (1983). Delirium in terminally ill cancer patients. American Journal of Psychiatry, 140, 1048–1050.Google Scholar
Melkersson, K. & Dahl, M.L. (2004). Adverse metabolic effects associated with atypical antipsychotics: Literature review and clinical implications. Drugs, 64, 701–723.Google Scholar
Mittal, D., Jimerson, N.A., Neely, E.P., et al. (2004). Risperidone in the treatment of delirium: Results from a prospective open-label trial. Journal of Clinical Psychiatry, 65, 662–667.Google Scholar
Miyamoto, S., Duncan, G.E., Marx, C.E., et al. (2005). Treatments for schizophrenia: A critical review of pharmacology and mechanisms of action of antipsychotic drugs. Molecular Psychiatry, 10, 79–104.Google Scholar
Nasrallah, H.J. & Newcomer, J.W. (2004). Atypical antipsychotics and metabolic dysregulation: Evaluating the risk/benefit equation and improving the standard of care. Journal of Clinical Psychopharmacology, 24, S7–S14.Google Scholar
Pae, C.U., Lee, S.J., Lee, C.U., et al. (2004). A pilot trial of quetiapine for the treatment of patients with delirium. Human Psychopharmacology, 19, 125–127.Google Scholar
Parellada, E., Baeza, I., de Pablo, J., et al. (2004). Risperidone in the treatment of patients with delirium. Journal of Clinical Psychiatry, 65, 348–353.Google Scholar
Platt, M.M., Breitbart, W., Smith, M., et al. (1994). Efficacy of neuroleptics for hypoactive delirium. Journal of Neuropsychiatry and Clinical Neurosciences, 6, 66–67.Google Scholar
Raedler, T.J., Knable, M.B., Jones, D.W., et al. (2000). In vivo olanzapine occupancy of muscarinic acetylcholine receptors in patients with schizophrenia. Neuropsychopharmacology, 23, 56–68.Google Scholar
Robertsson, B. (1999). Assessment scales in delirium. Dementia and Geriatric Cognitive Disorders, 10, 368–379.Google Scholar
Rockwood, K. (1993). The occurrence and duration of symptoms in elderly patients with delirium. Journal of Gerontology, 48, M162–M166.Google Scholar
Sasaki, Y., Matsuyama, T., Inoue, S., et al. (2003). A prospective, open-label, flexible-dose study of quetiapine in the treatment of delirium. Journal of Clinical Psychiatry, 64, 1316–1321.Google Scholar
Schwartz, T.L. & Masand, P.S. (2000). Treatment of delirium with quetiapine. Primary Care Companion to the Journal of Clinical Psychiatry, 2, 10–12.Google Scholar
Schwartz, T.L. & Masand, P.S. (2002). The role of atypical antipsychotics in the treatment of delirium. Psychosomatics, 43, 171–174.Google Scholar
Sipahimalani, A. & Masand, P.S. (1998). Olanzapine in the treatment of delirium. Psychosomatics, 39, 422–430.Google Scholar
Skrobik, Y.K., Bergeron, N., Dumont, M., et al. (2004). Olanzapine vs. haloperidol: Treating delirium in a critical care setting. Intensive Care Medicine, 30, 444–449.Google Scholar
Someya, T., Endo, T., Hara, T., et al. (2001). A survey on the drug therapy for delirium. Psychiatry and Clinical Neurosciences, 55, 397–401.Google Scholar
Tejera, C.A., Saravay, S.M., Goldman, E., et al. (1994). Diphenhydramine-induced delirium in elderly hospitalized patients with mild dementia. Psychosomatics, 35, 399–402.Google Scholar
Trzepacz, P.T. (1999). Update on the neuropathogenesis of delirium. Dementia and Geriatric Cognitive Disorders, 10, 330–334.Google Scholar
Trzepacz, P.T. (2000). Is there a final common neural pathway in delirium? Focus on acetylcholine and dopamine. Seminars in Clinical Neuropsychiatry, 5, 132–148.Google Scholar
Trzepacz, P.T., Baker, R.W., & Greenhouse, J. (1988). A symptom rating scale for delirium. Psychiatry Research, 23, 89–97.Google Scholar
Trzepacz, P.T., Breitbart, W., Franklin, J., et al. (1999). Practice guideline for the treatment of patients with delirium. American Psychiatric Association. American Journal of Psychiatry, 156, 1–20.Google Scholar
Trzepacz, P.T., Mittal, D., Torres, R., et al. (2001). Validation of the Delirium Rating Scale-revised-98: Comparison with the delirium rating scale and the cognitive test for delirium. Journal of Neuropsychiatry and Clinical Neurosciences, 13, 229–242.Google Scholar
Trzepacz, P.T., Sclabassi, R.J., & Van Thiel, D.H. (1989). Delirium: A subcortical phenomenon? Journal of Neuropsychiatry and Clinical Neurosciences, 1, 283–290.Google Scholar
Tuomisto, L., Lozeva, V., Valjakka, A., et al. (2001). Modifying effects of histamine on circadian rhythms and neuronal excitability. Behavioural Brain Research, 124, 129–135.Google Scholar
Wengel, S.P., Roccaforte, W.H., & Burke, W.J. (1998). Donepezil improves symptoms of delirium in dementia: Implications for future research. Journal of Geriatric Psychiatry and Neurology, 11, 159–161.Google Scholar
Wooltorton, E. (2002). Risperidone (Risperdal): Increased rate of cerebrovascular events in dementia trials. Canadian Medical Association Journal, 167, 1269–1270.Google Scholar
Yokota, H., Ogawa, S., Kurokawa, A., et al. (2003). Regional cerebral blood flow in delirium patients. Psychiatry and Clinical Neurosciences, 57, 337–339.Google Scholar
Young, C.C. & Lujan, E. (2004). Intravenous ziprasidone for treatment of delirium in the intensive care unit. Anesthesiology, 101, 794–795.Google Scholar