Delirium in Elderly People: An Update

Albert F.G. Leentjens; Rose C. van der Mast

Disclosures

Curr Opin Psychiatry. 2005;18(3):325-330. 

In This Article

Treatment

Given the negative influence of delirium on outcome, delirium should be considered an important complication of the underlying disease or its treatment, and treated accordingly. Although in need of an update, the 'Practice guidelines for the treatment of patients with delirium' of the American Psychiatric Association (APA) is the most comprehensive guideline on the treatment of this disorder. According to this guideline, haloperidol is the standard drug treatment of delirium.[35] Ample experience with haloperidol in elderly and in medically ill patients exists. The possibility of intravenous administration, although not approved by the Food and Drug Administration (FDA), may also be an advantage. Although, because of their more favourable motor side-effect profile, atypical antipsychotics may be preferred in elderly people, there is, as yet, no convincing evidence of their efficacy, with the exception of some lower-level evidence of risperidone. Several trials have recently demonstrated the positive effects of risperidone in older patients with delirium. One small double-blind randomized trial has directly compared risperidone and haloperidol in 28 patients with delirium. Both groups showed considerable improvement on the Memorial Delirium Assessment Scale, without any in-between group differences.[36*] In an open study in 10 patients, a dosage of risperidone 0.5 mg twice daily was effective in reducing the delirious symptoms, as measured by the Cognitive Test for Delirium (CTD) and the DRS.[37] One patient had to discontinue risperidone treatment because of sedation and hypotension. No patient developed extrapyramidal side effects. Parella et al .[38] reported effectiveness of an average dosage of 2.6 mg risperidone daily in 91% of 64 patients who were hospitalized for delirium. One patient experienced drowsiness and one suffered from nausea, but, again, no patient developed extrapyramidal symptoms. Other atypical antipsychotics have not been studied for the treatment of delirium in elderly people.

There have been no studies of delirium treatment in patients with Parkinson's disease, who have a strong contraindication for haloperidol because of potential exacerbation of extrapyramidal symptoms. There have been, however, quite a number of studies on treatment of medication-induced psychosis that may be potentially helpful in our choice of treatment for delirium in these patients. Evidence at the highest level exists for clozapine. This agent has been shown to be effective in reducing medication-induced hallucinations and psychosis in patients with Parkinson's disease in two double-blind, randomized, placebo-controlled trials, without negatively affecting motor symptoms.[39,40] Risperidone worsened extrapyramidal symptoms to some degree, while olanzapine was not more effective than placebo.[41,42] In one study that compared quetiapine and clozapine in a randomized open-label trial with blinded raters, 60 patients showed substantial improvement in delirious symptoms, without negative effects on motor function for both drugs.[43]

There is no evidence that delirium in demented patients has to be treated differently from delirium in non-demented patients, although, in Lewy body dementia, haloperidol is contraindicated and pro-cholinergic agents may be considered. In a large, randomized, double-blind, placebo-controlled trial among patients with Lewy body dementia, rivastigmine was significantly more effective than placebo in the treatment of apathy and psychotic symptoms, without negative effects on motor function.[44]

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