New Delirium Review in American Journal of Psychiatry

I thought I’d share the abstract of a new review on pharmacological treatments for delirium which was recently published in the American Journal of Psychiatry [1]. It’s important to realize this does not cover the treatment of substance withdrawal delirium, nor does it apply to delirium in patients less than 18 years old.

I’m always harping on my pet peeve that delirium is not a primary psychiatric problem per se and that the safest policy to follow is to regard it mainly as a medical emergency. Articles like the one Friedman and colleagues publish, while extremely valuable to the field of delirium research, tend to keep the focus on psychiatrists as being the champions of this critically important issue in the provision of high-quality health care.

It’s very interesting to note this and to be aware that the American Psychiatric Association (APA) practice guideline on the Treatment of Delirium have not been updated since 2004. The original guideline set was published in 1999, three years after my graduation from residency. The APA’s opinion of its own guideline is telling:

This guideline is more than 5 years old and has not yet been updated to ensure that it reflects current knowledge and practice. In accordance with national standards, including those of the Agency for Healthcare Research and Quality’s National Guideline Clearinghouse, this guideline can no longer be assumed to be current. The August 2004 Guideline Watch associated with this guideline provides additional information that has become available since publication of the guideline, but it is not a formal update of the guideline.

It’s puzzling that the APA has not tapped the APA Council on Psychosomatic Medicine, which includes many members of the Academy of Psychosomatic Medicine (APM) for help with updating the practice guidelines for delirium. One of the resident members of the council will be graduating this year from our combined internal medicine-psychiatry residency program at The University of Iowa. Maybe he’ll get the ball rolling.

And while my recently launched survey at link http://jdelirproj.polldaddy.com/s/reform-or-remove-maintenance-of-certification on the Maintenance of Certification (MOC) is anything but scientific, it’s so far getting more responses than my single question poll about whether there should be a Performance in Practice (PIP) clinical activity for delirium for MOC credit included in the selection currently available to American Board of Psychiatry and Neurology (ABPN) time-limited certificate holders. I think the current selection is simply not relevant to the practice of most general hospital psychiatric consultants. The poll got no votes at all.

However, the survey has captured a handful of responses. I included a question about whether or not a PIP activity for delirium should be developed for MOC credit for psychiatrists. Only 14% of respondents support it. On the other hand, 100% of respondents believe the MOC itself should be abandoned. Ironically, one of the comments was from an internist, who, If I’m interpreting the comment correctly, didn’t think the PIP activity for delirium was even relevant to internal medicine physicians. Please take the survey; the post containing essential information for completing it is here.

I wonder if the American Board of Internal Medicine (ABIM) includes a PIP activity for delirium for its MOC program.

What I see here is a conflict between internal medicine and psychiatry about which medical specialist should take ownership for delirium. I happen to think that it should be internal medicine because the cause of delirium, by definition, is medical. However, I can tell you that the vast majority of the consultation requests I get are from internists who haven’t a clue about what delirium is or what they should do about it. The scope of practice issues are clear, in my opinion. As a consulting psychiatrist, I can tell an internist what delirium is not–it’s not a primary psychiatric problem per se. I can also emphasize that the main recommendation is to search for and treat the underlying medical causes. Internists are trained to do that; the vast majority of psychiatrists are not.

That doesn’t mean that psychiatrists have nothing to offer within a team-based, collaborative care framework to provide the safest, high-quality medical care which is the cornerstone of a patient-centered approach for preventing delirium.

Which brings me to the main point of the review article about pharmacologic interventions for delirium. As so many others have repeatedly pointed out, it’s the prevention efforts that are most likely to have an impact on the enormous and tragic toll that delirium exacts on our patients and their families. If you want to focus on dollars and cents, then delirium sucks billions annually from our health care system. While I don’t believe every case of delirium can be prevented, there is abundant literature showing that even non-pharmacologic methods can prevent about a third of the cases.

So when it comes to pharmacologic prevention methods, Friedman and colleagues are very clear on the evidence that some controlled studies demonstrate that preventing delirium using selected psychotropic medications is at least possible–and once delirium gets established, there’s not a lot of evidence that psychiatric drug treatments are that helpful. This systematic analysis is itself evidence for the important role that psychiatrists play in this effort because the medications most frequently cited are in the antipsychotic class. And the drug most often identified as being effective? It’s haloperidol.

That’s not news. On the other hand, if psychiatrists want to be on the playing field in delirium prevention, then at the very least the APA and other major organizations including the APM and the American Delirium Society could work together to update the APA delirium practice guidelines.

Do patients and families think that a MOC program should include a delirium PIP activity? If you take the survey, we could find out. You can identify yourselves as non-physicians in the comment section linked to the question.

Reference:

1. Friedman, J. I., et al. (2013). “Pharmacological Treatments of Non-Substance-Withdrawal Delirium: A Systematic Review of Prospective Trials.” Am J Psychiatry.
OBJECTIVE Most reviews of pharmacological strategies for delirium treatment evaluate the effectiveness of these interventions for delirium prevention, reduction in duration and severity of ongoing delirium, and other outcomes that extend beyond the recommendations of expert treatment guidelines. However, little if any attention is given to substantiating the potential benefits of such treatment or addressing the methodological weaknesses that, in part, limit the pharmacological recommendations made by expert treatment guidelines. Therefore, the authors conducted a systematic review to provide the most up-to-date and inclusive review of published prospective trials of potential pharmacological interventions for the prevention and treatment of delirium, and they discuss potential benefits of pharmacological prevention of delirium and/or reduction of ongoing delirium episode duration and severity. METHOD The analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including prospective randomized and nonrandomized double-blind, single-blind, and open-label clinical trials of any pharmacological agent for the prevention or treatment of delirium and reviewing them systematically for effectiveness on several predefined outcomes. RESULTS The pharmacological strategies reviewed showed greater success in preventing delirium than in treating it. Significant delirium prevention effects are associated with haloperidol, second-generation antipsychotics, iliac fascia block, gabapentin, melatonin, lower levels of intraoperative propofol sedation, and a single dose of ketamine during anesthetic induction and with dexmedetomidine compared with other sedation strategies for mechanically ventilated patients. CONCLUSIONS These promising results warrant further study with consideration of the methodological weaknesses and inconsistencies of studies to date.

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