Study Identifies Medications Effective for Treating, Preventing Delirium

Delirium—an acute brain state characterized by confused thoughts and emotions—is a common problem among elderly inpatients and patients in intensive care. A meta-analysis published in JAMA Psychiatry suggests that a combination of haloperidol and lorazepam may be the best option to treat patients with delirium, while ramelteon may be the best medication to prevent delirium.

Yi-Cheng Wu, M.D., of Linkou Chang Gung Memorial Hospital in Taoyuan, Taiwan, and colleagues compiled data from 58 clinical trials for delirium; these included 20 trials assessing therapeutic interventions for delirium and 38 assessing preventive interventions. The trials involved more than 9,600 individuals who had delirium due to a variety of possible causes such as being in critical care, undergoing major surgery, having a chronic illness like cancer, or being of advanced age.

Among the studies testing medications to treat delirium, only patients given haloperidol (currently the most commonly used medication for delirium) or haloperidol plus lorazepam had better response rates (fewer delirium-related symptoms) than those given placebo. The haloperidol-lorazepam combination was superior, according to the analysis; patients prescribed haloperidol plus lorazepam were 28 times more likely to respond than those prescribed placebo, while patients prescribed haloperidol were about 2.4 times as likely to achieve a response than those prescribed placebo.

Among the 38 preventive studies, four treatments were found superior to placebo at reducing the risk of delirium: dexmedetomidine hydrochloride, olanzapine, ramelteon, and risperidone. Of these, ramelteon had the strongest preventive effect, reducing the risk of delirium by 93% relative to placebo.

The study authors cautioned, however, that haloperidol-lorazepam and ramelteon were studied in only one trial each. “Future large-scale RCTs investigating the treatment effect of haloperidol plus lorazepam and the preventive effect of ramelteon are warranted to corroborate the findings,” they concluded.

To read more about the management of delirium, see the Psychiatric News article “Common Delirium Medications Found Not Effective in Critically Ill Patients” and the Journal of Neuropsychiatry and Clinical Neurosciences article “Responding to Ten Common Delirium Misconceptions With Best Evidence: An Educational Review for Clinicians.”

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Catatonia Often Goes Undiagnosed, Untreated in General Hospitals

Physicians fail to diagnose the majority of cases of catatonia in a general hospital setting, which may result in suboptimal treatment for these patients, according to an article in the Journal of Neuropsychiatry and Clinical Neurosciences. However, psychiatric consultation can significantly decrease the odds of failure to diagnose the condition, the study found.

Diagnosing catatonia is challenging because it requires clinical suspicion and physical examination, according to researchers Joan Roig Llesuy, M.D., of New York University School of Medicine and colleagues. While catatonia is often reversible when treated with lorazepam and/or electroconvulsive therapy (ECT), its underrecognition and subsequent lack of treatment might lead to dangerous medical complications, the authors wrote.

Moreover, failure to recognize catatonia may lead to improper treatment with antipsychotics, which can increase the risk for developing malignant catatonic features or neuroleptic malignant syndrome. “Thus, awareness about catatonia for all clinicians is relevant to improve patient care,” the authors wrote.

The study involved a retrospective chart review of adult inpatients at the University of Chicago general hospital between 2011 and 2013. The presence of three or more keywords in the chart describing catatonia-related signs was used to flag cases for review. Of 133 cases found meeting DSM-5 criteria for catatonia, 79 (nearly 60%) were not diagnosed with the condition.

Additional analysis revealed that patients meeting DSM-5 criteria for catatonia who underwent a psychiatric consultation during the admission process were more than 44 times as likely to be correctly diagnosed with catatonia, compared with those who did not receive a consultation. Still, more than one-third of undiagnosed patients (37%) had received a psychiatry consult, supporting “the need for greater recognition of catatonia across disciplines,” the researchers wrote.

Physicians may be unaware of the cluster of signs and symptoms that constitute catatonia: the presence of grimacing, agitation, or echolalia symptoms was associated with a 4 to 6 times greater likelihood that the catatonia would go undiagnosed.

Regardless of diagnosis of catatonia, none of the 133 subjects received ECT. Also, no differences were found in the rate of lorazepam treatment between diagnosed or undiagnosed patients: half of those with catatonia did not receive lorazepam. However, the total dose of lorazepam was significantly lower in the undiagnosed group, who received 0.4 mg a day on average versus those diagnosed with catatonia, who received an average of 1.3 mg a day. High doses of lorazepam for several days or longer might be needed to treat catatonia effectively, the researchers wrote.

“Improving detecting and treatment of catatonia could help improve clinical outcomes of patients with this reversible syndrome in the general hospital,” concluded the authors.

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Suspected Delirium Predicts the Thoroughness of Catatonia Evaluation.”

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