Delirium in hospitalized adults: Situation critical, no relief available

Every year as many as seven million adults in the United States experience delirium during hospitalization. In a systematic review of the scientific literature on delirium prevention and treatment, investigators from the Regenstrief Institute, Indiana University, and Wishard Health Services found that despite the significant health and financial burdens of delirium for hospitalized adults, no effective way to prevent or treat the condition has been identified.

"Having delirium prolongs the length of a hospital stay, increases the risk of post-hospitalization transfer to a nursing home and doubles the risk of death. We need to identify a safe and effective drug to prevent and treat delirium. With our review, we are challenging the scientific community to come up with new therapeutic options," said Malaz Boustani, M.D., senior author of the study which appears in the July 2009 issue of the Journal of General Internal Medicine.

Delirium, experienced by a significant number of older patients in surgical and critical care units and over half of older adults who are hospitalized for broken hips, is a state of confusion in which the individual has undergone a sudden alteration of mental status. Delirium is not dementia, but individuals with dementia are more susceptible to developing delirium during hospitalization than individuals without dementia.

The researchers found that only 13 randomized controlled studies on promising drugs for delirium were conducted from January 1966 to October 2008. These studies identified and evaluated 15 drugs including first and second generation antipsychotics, the drugs currently prescribed by most physicians for patients with delirium. The researchers found that neither older agents nor newer, more expensive medications were effective in preventing delirium. The study also found no difference between antipsychotics in treating delirium. To date, there are no U.S. Food and Drug Administration approved drugs to prevent or manage delirium.

"Research on delirium is at a point similar to where Alzheimer disease research was 30 years ago. The scientific and policy communities should encourage the FDA to provide guidance regarding the evaluation of potential new therapies for delirium. Hopefully this will promote rapid drug discovery and translation into delivery for patient care," said Dr. Boustani.

For vulnerable older adults only a slight insult, such as developing a urinary tract infection or taking an over-the-counter drug with anti-cholinergic effects (including many popular brands of sleeping pills), may lead to delirium. Less vulnerable individuals may require a more major insult, such as a stroke or heart attack, to trigger delirium, according to Dr. Boustani, who sees patients at the Healthy Aging Brain Center at the IU Center for Senior Health at Wishard.

"Our review found that drugs that affect the sleep-wake cycle, or that manage pain after surgery, may help prevent delirium," said Wishard Health Services pharmacist Noll Campbell, Pharm.D., first author of the study. "However, these treatment targets remain preliminary and require further study before they are accepted into widespread use."

Authors of the JGIM study are Dr, Boustani; Dr. Campbell and Oscar Guzman, Pharm.D., of Wishard; Amir Ayub, M.D., of the IU Center for Aging Research and the IU School of Medicine; George C. Fox, MRCPsych, University of Kent; Stephanie L. Munger, B.S., of Regenstrief and the IU Center for Aging Research; Carol Ott, PharmD, Purdue University; Mark Farber, MD, IU School of Medicine; and Adetayo Ademuyiwa, M.D., and Ranjeet Singh, M.D., of Indiana University - Purdue University Indianapolis.

The systematic evidence review was funded by the John A. Hartford Foundation, the Atlantic Philanthropies, the Starr Foundation, the National Institute on Aging and the American Federation of Aging Research.