Delirium primary prevention: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Delirium}} | {{Delirium}} | ||
{{CMG}}; {{AE}} {{PB}} | {{CMG}}; {{AE}} {{Sara.Zand}} {{PB}} | ||
==Overview== | ==Overview== | ||
It is important to prevent delirium as delirium is itself neurotoxic. | It is important to prevent [[delirium]] as [[delirium]] is itself [[neurotoxic]]. [[Delirium]] is associated with global [[brain]] atrophy and [[white matter]] disruption. Various non pharmacological and pharmacological interventions are found to be effective to prevent [[delirium]]. [[Primary prevention]] sterategy for Post-operative [delirium]] include use of [[haloperidol]], second generation [[antipsychotics]], iliac fascia block, lower levels of intraoperative [[ propofol]] for sedation, continuous intravenous infusion of [[dexmedetomidine]], [[Melatonin]]. [[ketamine]] is not useful in preventing postoperative [[delirium]]. Preoperative administration of [[gabapentin]] is not effective for prevention of postoperative [[delirium]]. | ||
==Primary Prevention== | ==Primary Prevention== | ||
Effective measures for the primary prevention of [[delirium]] include pharmacologic and nonpharmacologic approaches. | Effective measures for the primary prevention of [[delirium]] include pharmacologic and nonpharmacologic approaches. | ||
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===Pharmacological Interventions=== | ===Pharmacological Interventions=== | ||
* Post operative [[delirium]]<ref name="pmid31354253">{{cite journal |vauthors=Janssen TL, Alberts AR, Hooft L, Mattace-Raso F, Mosk CA, van der Laan L |title=Prevention of postoperative delirium in elderly patients planned for elective surgery: systematic review and meta-analysis |journal=Clin Interv Aging |volume=14 |issue= |pages=1095–1117 |date=2019 |pmid=31354253 |pmc=6590846 |doi=10.2147/CIA.S201323 |url=}}</ref> | * Primary prevention sterategy for Post operative [[ patients]] [[delirium]] include the following:<ref name="pmid31354253">{{cite journal |vauthors=Janssen TL, Alberts AR, Hooft L, Mattace-Raso F, Mosk CA, van der Laan L |title=Prevention of postoperative delirium in elderly patients planned for elective surgery: systematic review and meta-analysis |journal=Clin Interv Aging |volume=14 |issue= |pages=1095–1117 |date=2019 |pmid=31354253 |pmc=6590846 |doi=10.2147/CIA.S201323 |url=}}</ref> | ||
:* [[Haloperidol]] | :* [[Haloperidol]] | ||
:* Second-generation [[antipsychotics]] | :* Second-generation [[antipsychotics]] | ||
:* [[Iliac]] fascia block | :* [[Iliac]] fascia block<ref name="ScurrahShiner2018">{{cite journal|last1=Scurrah|first1=A.|last2=Shiner|first2=C. T.|last3=Stevens|first3=J. A.|last4=Faux|first4=S. G.|title=Regional nerve blockade for early analgesic management of elderly patients with hip fracture - a narrative review|journal=Anaesthesia|volume=73|issue=6|year=2018|pages=769–783|issn=00032409|doi=10.1111/anae.14178}}</ref> | ||
:* Lower levels of intraoperative [[propofol]] sedation<ref name="DjaianiSilverton2016">{{cite journal|last1=Djaiani|first1=George|last2=Silverton|first2=Natalie|last3=Fedorko|first3=Ludwik|last4=Carroll|first4=Jo|last5=Styra|first5=Rima|last6=Rao|first6=Vivek|last7=Katznelson|first7=Rita|title=Dexmedetomidine versus Propofol Sedation Reduces Delirium after Cardiac Surgery|journal=Anesthesiology|volume=124|issue=2|year=2016|pages=362–368|issn=0003-3022|doi=10.1097/ALN.0000000000000951}}</ref> | :* Lower levels of intraoperative [[propofol]] sedation<ref name="DjaianiSilverton2016">{{cite journal|last1=Djaiani|first1=George|last2=Silverton|first2=Natalie|last3=Fedorko|first3=Ludwik|last4=Carroll|first4=Jo|last5=Styra|first5=Rima|last6=Rao|first6=Vivek|last7=Katznelson|first7=Rita|title=Dexmedetomidine versus Propofol Sedation Reduces Delirium after Cardiac Surgery|journal=Anesthesiology|volume=124|issue=2|year=2016|pages=362–368|issn=0003-3022|doi=10.1097/ALN.0000000000000951}}</ref> | ||
:* Continuous [[intravenous ]] infusion of [[dexmedetomidine]]<ref name="pmid30238227">{{cite journal |vauthors=Flükiger J, Hollinger A, Speich B, Meier V, Tontsch J, Zehnder T, Siegemund M |title=Dexmedetomidine in prevention and treatment of postoperative and intensive care unit delirium: a systematic review and meta-analysis |journal=Ann Intensive Care |volume=8 |issue=1 |pages=92 |date=September 2018 |pmid=30238227 |pmc=6148680 |doi=10.1186/s13613-018-0437-z |url=}}</ref> | |||
:* Continuous [[intravenous ]] infusion of [[dexmedetomidine]] | |||
:* [[Melatonin]]<ref name="CampbellAxon2019">{{cite journal|last1=Campbell|first1=Ashley M.|last2=Axon|first2=David Rhys|last3=Martin|first3=Jennifer R.|last4=Slack|first4=Marion K.|last5=Mollon|first5=Lea|last6=Lee|first6=Jeannie K.|title=Melatonin for the prevention of postoperative delirium in older adults: a systematic review and meta-analysis|journal=BMC Geriatrics|volume=19|issue=1|year=2019|issn=1471-2318|doi=10.1186/s12877-019-1297-6}}</ref> | :* [[Melatonin]]<ref name="CampbellAxon2019">{{cite journal|last1=Campbell|first1=Ashley M.|last2=Axon|first2=David Rhys|last3=Martin|first3=Jennifer R.|last4=Slack|first4=Marion K.|last5=Mollon|first5=Lea|last6=Lee|first6=Jeannie K.|title=Melatonin for the prevention of postoperative delirium in older adults: a systematic review and meta-analysis|journal=BMC Geriatrics|volume=19|issue=1|year=2019|issn=1471-2318|doi=10.1186/s12877-019-1297-6}}</ref> | ||
*[[ | *[[ketamine]] is not useful in preventing postoperative [[delirium]]. <ref name="pmid28576285">{{cite journal |vauthors=Avidan MS, Maybrier HR, Abdallah AB, Jacobsohn E, Vlisides PE, Pryor KO, Veselis RA, Grocott HP, Emmert DA, Rogers EM, Downey RJ, Yulico H, Noh GJ, Lee YH, Waszynski CM, Arya VK, Pagel PS, Hudetz JA, Muench MR, Fritz BA, Waberski W, Inouye SK, Mashour GA |title=Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial |journal=Lancet |volume=390 |issue=10091 |pages=267–275 |date=July 2017 |pmid=28576285 |pmc=5644286 |doi=10.1016/S0140-6736(17)31467-8 |url=}}</ref> | ||
* Preoperative administration of [[gabapentin]] is not effective for prevention of postoperative [[delirium]].<ref>{{cite journal|doi=10.1097/ALN.0000000000001804.}}</ref> | |||
====[[Haloperidol]]==== | ====[[Haloperidol]]==== | ||
[[Delirium]] possibly causes exhaustion leading to respiratory difficulties and a higher incidence of re-[[intubations]]. | *[[Delirium]] possibly causes exhaustion leading to respiratory difficulties and a higher incidence of re-[[intubations]]. | ||
Low dose [[haloperidol]], if given prophylactically in lower doses, have a better prognosis than treatment of [[delirium]]. | *Low dose [[haloperidol]], if given prophylactically in lower doses, have a better prognosis than treatment of [[delirium]]. | ||
* The following benefits were observed: | * The following benefits were observed: | ||
* Lower [[mortality]] | * Lower [[mortality]] | ||
Latest revision as of 11:15, 22 April 2021
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Pratik Bahekar, MBBS [3]
Overview
It is important to prevent delirium as delirium is itself neurotoxic. Delirium is associated with global brain atrophy and white matter disruption. Various non pharmacological and pharmacological interventions are found to be effective to prevent delirium. Primary prevention sterategy for Post-operative [delirium]] include use of haloperidol, second generation antipsychotics, iliac fascia block, lower levels of intraoperative propofol for sedation, continuous intravenous infusion of dexmedetomidine, Melatonin. ketamine is not useful in preventing postoperative delirium. Preoperative administration of gabapentin is not effective for prevention of postoperative delirium.
Primary Prevention
Effective measures for the primary prevention of delirium include pharmacologic and nonpharmacologic approaches.
Non Pharmacological Interventions
- Nonpharmacological approaches may curtail the incidence of delirium.
- Following are a few preventive strategies for delirium:[1]
Curtail cognitive decline
- Write names of care providers, the day’s schedule on board
- Constantly reorient patients to surroundings
- Activities to stimulate cognitive actions like discussion of current events, structured reminiscence, or word games
Curtail sleep impairment
- Reduce environmental noise
- Relaxing activities such as music, back massage
Curtail immobility
Manage difficulties in sight
Manage difficulties in hearing
Avoid dehydration
Pharmacological Interventions
- Haloperidol
- Second-generation antipsychotics
- Iliac fascia block[4]
- Lower levels of intraoperative propofol sedation[5]
- Continuous intravenous infusion of dexmedetomidine[6]
- Melatonin[7]
- ketamine is not useful in preventing postoperative delirium. [8]
- Preoperative administration of gabapentin is not effective for prevention of postoperative delirium.[9]
Haloperidol
- Delirium possibly causes exhaustion leading to respiratory difficulties and a higher incidence of re-intubations.
- Low dose haloperidol, if given prophylactically in lower doses, have a better prognosis than treatment of delirium.
- The following benefits were observed:
- Lower mortality
- Lower delirium incidence
- More delirium free days
- Patients are less likely to remove their tubes or catheters
- Patients with a higher risk of developing delirium benefited more
- ICU readmission rate was lower.
- Drawbacks of prophylactic treatment with Haloperidol:
- Unnecessary treatment to patients who were not destined to develop delirium
- Side effects of treatment, however during clinical studies there was only a marginal prolongation of QTc and no one developed ventricular arrhythmias.
References
- ↑ Ghaeli P, Shahhatami F, Mojtahed Zade M, Mohammadi M, Arbabi M (April 2018). "Preventive Intervention to Prevent Delirium in Patients Hospitalized in Intensive Care Unit". Iran J Psychiatry. 13 (2): 142–147. PMC 6037578. PMID 29997660.
- ↑ "MMS: Error".
- ↑ Janssen TL, Alberts AR, Hooft L, Mattace-Raso F, Mosk CA, van der Laan L (2019). "Prevention of postoperative delirium in elderly patients planned for elective surgery: systematic review and meta-analysis". Clin Interv Aging. 14: 1095–1117. doi:10.2147/CIA.S201323. PMC 6590846 Check
|pmc=value (help). PMID 31354253. - ↑ Scurrah, A.; Shiner, C. T.; Stevens, J. A.; Faux, S. G. (2018). "Regional nerve blockade for early analgesic management of elderly patients with hip fracture - a narrative review". Anaesthesia. 73 (6): 769–783. doi:10.1111/anae.14178. ISSN 0003-2409.
- ↑ Djaiani, George; Silverton, Natalie; Fedorko, Ludwik; Carroll, Jo; Styra, Rima; Rao, Vivek; Katznelson, Rita (2016). "Dexmedetomidine versus Propofol Sedation Reduces Delirium after Cardiac Surgery". Anesthesiology. 124 (2): 362–368. doi:10.1097/ALN.0000000000000951. ISSN 0003-3022.
- ↑ Flükiger J, Hollinger A, Speich B, Meier V, Tontsch J, Zehnder T, Siegemund M (September 2018). "Dexmedetomidine in prevention and treatment of postoperative and intensive care unit delirium: a systematic review and meta-analysis". Ann Intensive Care. 8 (1): 92. doi:10.1186/s13613-018-0437-z. PMC 6148680. PMID 30238227.
- ↑ Campbell, Ashley M.; Axon, David Rhys; Martin, Jennifer R.; Slack, Marion K.; Mollon, Lea; Lee, Jeannie K. (2019). "Melatonin for the prevention of postoperative delirium in older adults: a systematic review and meta-analysis". BMC Geriatrics. 19 (1). doi:10.1186/s12877-019-1297-6. ISSN 1471-2318.
- ↑ Avidan MS, Maybrier HR, Abdallah AB, Jacobsohn E, Vlisides PE, Pryor KO, Veselis RA, Grocott HP, Emmert DA, Rogers EM, Downey RJ, Yulico H, Noh GJ, Lee YH, Waszynski CM, Arya VK, Pagel PS, Hudetz JA, Muench MR, Fritz BA, Waberski W, Inouye SK, Mashour GA (July 2017). "Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial". Lancet. 390 (10091): 267–275. doi:10.1016/S0140-6736(17)31467-8. PMC 5644286. PMID 28576285.
- ↑ . doi:10.1097/ALN.0000000000001804. Check
|doi=value (help). Missing or empty|title=(help) - ↑ "Haloperidol prophylaxis in critically ill patients... [Crit Care. 2013] - PubMed - NCBI".
- ↑ Schrijver, Edmée JM; de Vries, Oscar J; Verburg, Astrid; de Graaf, Karola; Bet, Pierre M; van de Ven, Peter M; Kamper, Ad M; Diepeveen, Sabine HA; Anten, Sander; Siegel, Andrea; Kuipéri, Esther; Lagaay, Anne M; van Marum, Rob J; van Strien, Astrid M; Boelaarts, Leo; Pons, Douwe; Kramer, Mark HH; Nanayakkara, Prabath WB (2014). "Efficacy and safety of haloperidol prophylaxis for delirium prevention in older medical and surgical at-risk patients acutely admitted to hospital through the emergency department: study protocol of a multicenter, randomised, double-blind, placebo-controlled clinical trial". BMC Geriatrics. 14 (1). doi:10.1186/1471-2318-14-96. ISSN 1471-2318.