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Delirium Definition
Delirium
Delirium is Common
Delirium
usually has an underlying physiological etiology In a general hospital setting the occurrence of Delirium may approach
30% in medically ill patients 40% in the hospitalized elderly 85% in cancer patients and for those with terminal illness
is associated with poor functional outcome, prolonged hospitalization, and increased morbidity and mortality
the identification of underlying etiologies (ii) appropriate medical intervention to treat reversible etiologies (iii) initiation of environmental interventions to provide safety and support (iv) relief of distressing symptoms with antipsychotics
(IV or PO)
Seroquel
Ideally Treats delirium and provides sedation without significant EPS
Abilify
Case
Patient
with bipolar d/o presenting with hyperactive delirium (but not in a manic episode). Was on Abilify 15 mg Recommendation go up to 20 mg Patient improved clinically
Intriguing case?
Somewhat
surprised the intervention of increasing Abilify from 15 mg to 20 mg worked Lack of experience using or hearing about Abilify (specifically) used for delirium
Intriguing case?
Abilify
differs from all other antipsychotics by being a partial agonist (not a D2 blocker). . . Mechanism by which antipsychotics treat delirium unclear By being a partial D2 agonist could there be a difference could there be a difference in efficacy for treating delirium?
PICO Question
Patient
population: Delirious patients Intervention: Abilify Comparison: Other antipsychotics (non partial agonists either FGA or SGA) Outcome: Resolution of Delirium
In
patients with delirium, is Abilify as effective as other anti-psychotics in clearing the delirium?
Article
Aripiprazole
Soenke Boettger , Miriam Friedlander, William Breitbart Australian and New Zealand Journal of Psychiatry 2011; 45:477 482
Article Aim
To
further explore the efficacy and tolerability of Abilify (as compared with Haldol) in the treatment of delirium
Previous studies on this topic include a single published case series and two published case reports examining the safety & tolerability of Abilify Results from these studies showed a significant reduction in symptoms of delirium
Methods
This
paper performed a secondary analysis on patients with delirium who received Abilify and then compared this data to a case matched sample of subjects treated with Haldol. Retrospective chart review Essentially they compared reduction in MDAS scores between Haldol / Abilify.
Assessment Scale
10-item, four-point (0-3), clinician-rated scale The MDAS items reflect the diagnostic criteria
for delirium in the DSM-IV-TR and assess disturbance in arousal and level of consciousness, cognitive functioning (memory, attention, orientation, and perceptual disturbances) and psychomotor activity. MDAS scores greater than 10 identified the presence of delirium MDAS scores of less than 10 indicated the resolution of delirium in this analysis
Limitations
Paper based on retrospective analysis of prospectively collected data (Level 4 Evidence). Selection of neuroleptic based on psychiatrists preference Severely agitated patients were excluded from the analysis 21 Patients in each medication group (not a large analysis) This paper acknowledged the need for further randomized, double blind, controlled studies.
Type of Evidence Systematic review of RCTs Individual RCT (with narrow confidence interval) 2a Systematic review of cohort studies 2b Individual cohort study 3 Case control studies 4 Case Series (retrospective chart review) 5 (Worst) Expert Opinion, Editorials
Strengths
Authors
attempted to case match patients treated with Abilify to those treated with Haldol with both groups having similar:
Age Initial MDAS Scores Similar etiologies of delirium Similar ratios of subtypes of delirium: Hypoactive / hyperactive delirium were
Strengths
Analysis
was not sponsored by a pharmaceutical company. Although some of the authors had received grants from companies such as Lilly and Purdue-Pharma none reported affiliations to Bristol-Myers Squibb (Abilify pharmaceutical company) The authors alone are responsible for the content and writing of the paper.
none Haldol EPS (parkinsonism and dystonia). More likely at higher doses
Article Conclusions
There
was no significant difference in the ability of Abilify to ameliorate the symptoms of delirium more effectively than haloperidol at time points T2 and T3 in either subtype of delirium, hypoactive or hyperactive.
OR
Abilify
Article Conclusions
Abilify
My Conclusions
At
this time given the available evidence (although of lower grade) it seems reasonable to believe that Abilify and Haldol likely have relatively similar efficacies in treating delirium. However, more research is needed.
Again noting: this study was not strong enough to conclude this definitively (it was not a superiority trial, equivalence trial, a non-inferiority trial OR even a trial at all [it was a retrospective chart review])
My Thoughts
Article
conclusions seems in line with first principles but why limit to just Abilify and not all SGA vs. Haldol since SGAs as a class tend to have less EPS?