American Delirium Society Annual Meeting 2016!

This is a shout-out about the American Delirium Society (ADS) 2016 meeting, which will be held in Nashville, Tennessee June 1-3, 2016. The theme is “Improving Care Through the Integration of Science and Policy.” Those interested in presenting can download  the call for proposals here. Proposals for symposia, workshops and roundtables should be submitted by September 14, 2015.

I’ll probably be on duty again and will be unable to attend, but I wonder if anyone will be clarifying the role of psychostimulants in the treatment of hypoactive delirium. Most consulting psychiatrists don’t believe this intervention is ready for prime time but the idea comes up occasionally, mainly because of a persisting belief that drugs like methylphenidate can help delirious patients focus their attention, attentional dysfunction being the primary neurocognitive deficit in delirium.

I found at least one paper by W. Breitbart et al which casts doubt on that assumption [1].

And I couldn’t find it mentioned in the APM Delirium Monograph on the Academy of Psychosomatic Medicine web site. Maybe the idea that psychostimulants would be helpful is based in the belief that the mechanism of action in stimulants would be the same for delirium as it is for Attention Deficit Hyperactivity Disorder (ADHD), which is doubtful because of the complexity of the pathophysiology of delirium (it isn’t just dopamine that gets deranged). However, it’s not like there is no literature about it, though it tends to be focused in the cancer patient population [2,3].

The ADS meetings are designed for just these kinds of questions and are not to be missed if you can help it, so get there!

By the way, speaking of Dr. Breitbart, he sent an invitation to many of us to read about the International Psycho-oncology Society (IPOS) new Quality Standards and the IPOS Lisbon Declaration declaring Psychosocial Cancer Care as a Human Right, at link IPOS International Standard of Quality Cancer Care. You can endorse it on line.

It sure would be fantastic to see more signatures!

References:

  1. Breitbart, W. and Y. Alici (2012). “Evidence-based treatment of delirium in patients with cancer.” J Clin Oncol 30(11): 1206-1214.
    Delirium is the most common neuropsychiatric complication seen in patients with cancer, and it is associated with significant morbidity and mortality. Increased health care costs, prolonged hospital stays, and long-term cognitive decline are other well-recognized adverse outcomes of delirium. Improved recognition of delirium and early treatment are important in diminishing such morbidity. There has been an increasing number of studies published in the literature over the last 10 years regarding delirium treatment as well as prevention. Antipsychotics, cholinesterase inhibitors, and alpha-2 agonists are the three groups of medications that have been studied in randomized controlled trials in different patient populations. In patients with cancer, the evidence is most clearly supportive of short-term, low-dose use of antipsychotics for controlling the symptoms of delirium, with close monitoring for possible adverse effects, especially in older patients with multiple medical comorbidities. Nonpharmacologic interventions also appear to have a beneficial role in the treatment of patients with cancer who have or are at risk for delirium. This article presents evidence-based recommendations based on the results of pharmacologic and nonpharmacologic studies of the treatment and prevention of delirium.
  2. Gagnon, B., et al. (2005). “Methylphenidate hydrochloride improves cognitive function in patients with advanced cancer and hypoactive delirium: a prospective clinical study.” J Psychiatry Neurosci 30(2): 100-107.
    OBJECTIVE: To investigate the clinical improvement observed in patients with advanced cancer and hypoactive delirium after the administration of methylphenidate hydrochloride. METHODS: Fourteen patients with advanced cancer and hypoactive delirium were seen between March 1999 and August 2000 at the Palliative Care Day Hospital and the inpatient Tertiary Palliative Care Unit of Montreal General Hospital, Montreal. They were chosen for inclusion in a prospective clinical study on the basis of (1) cognitive failure documented by the Mini-Mental State Examination (MMSE), (2) sleep-wake pattern disturbances, (3) psychomotor retardation, (4) absence of delusions or hallucinations, and (5) absence of an underlying cause to explain the delirium. All patients were treated with methylphenidate, and changes in their cognitive function were measured using the MMSE. RESULTS: All 14 patients showed improvement in their cognitive function as documented by the MMSE. The median pretreatment MMSE score (maximum score 30) was 21 (mean 20.9, standard deviation [SD] 4.9), which improved to a median of 27 (mean 24.9, SD 4.7) after the first dose of methylphenidate (p < 0.001, matched, paired Wilcoxon signed rank test). One patient died before reaching a stable dose of methylphenidate. In the other 13 patients, the median MMSE score further improved to 28 (mean 27.8, SD 2.4) (p = 0.02 compared with the median MMSE score documented 1 hour after the first dose of methylphenidate). All patients showed an improvement in psychomotor activities. CONCLUSIONS: Hypoactive delirium that cannot be explained by an underlying cause (metabolic or drug-induced) in patients with advanced cancer appears to be a specific syndrome that could be improved by the administration of methylphenidate.
  3. Elie, D., et al. (2010). “[Using psychostimulants in end-of-life patients with hypoactive delirium and cognitive disorders: A literature review].” Can J Psychiatry 55(6): 386-393.
    OBJECTIVE: To review the research about psychostimulant effects on cognitive functions in end-of-life patients diagnosed with hypoactive delirium or cognitive disorders. METHOD: The MEDLINE (1966-March 2008), Embase (1974-March 2008), PsycINFO (1806-March 2008), IPA (1970-March 2008), CINAHL (1982-March 2008), ISI Web of Science (1945-March 2008), Current Contents (March 2007-March 2008), Access Medicine (2001-March 2008), and ProQuest Dissertations & Theses (1980-March 2008) databases were searched with keywords related to delirium, cognition, psychostimulants, and palliative care for French or English articles in a dementia-free and hyperactive delirium-free end-of-life population. Cognitive functions had to be assessed before and after initiation of the psychostimulant treatment. Moreover, treatment had to be initiated after the onset of cognitive impairments. RESULTS: A total of 173 studies were screened. Five studies on methylphenidate and 1 study on caffeine met inclusion criteria and were included in this review. Two studies were case reports, 2 were open-label trials, and 2 were double-blind, crossover randomized placebo-controlled trials. Three studies were conducted with hypoactive delirium patients and all studies were conducted in an advanced cancer patient population. CONCLUSIONS: The reviewed studies support the use of methylphenidate to improve end-of-life patient cognitive functions, particularly in the case of hypoactive delirium. Caffeine seems to have beneficial effects on psychomotor activity. Further well-designed studies are needed to consolidate these findings.
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