SANTA ANA PUEBLO, N.M. – Aripiprazole should be considered for treatment of prolonged delirium, especially in patients with significant medical comorbidity, Dr. David Straker said at the annual meeting of the Academy of Psychosomatic Medicine.
Dr. Straker reported that the atypical antipsychotic reduced Delirium Rating Scale-revised-98 scores by 50% or more for 12 of 14 patients in a case series at New York Presbyterian Hospital, Columbia University Medical Center in New York City. The average score fell from 25.1 to 9.4.
All 14 patients improved, according to Dr. Straker, now at Zucker Hillside Hospital, Long Island Jewish Medical Center, Glen Oaks, N.Y. Eight came off restraints, and six no longer required constant observation after treatment with aripiprazole (Abilify). “In this small case series, aripiprazole appeared to be safe and effective. Adverse side effects were minimal,” Dr. Straker said. “Aripiprazole may have a role in hypoactive, lethargic patients with delirium.”
Dr. Lawson R. Wulsin of the University of Cincinnati called the study much needed and urged that its results be shared with hospital physicians who are not psychiatrists. He said he hoped the “promising findings” would provide the impetus for an open-label or randomized clinical trial.
In an interview at the meeting, Dr. Straker said his schedule since completing a fellowship at Columbia did not allow him to organize a trial, but that one was needed, and he would like to participate. “I think it should be studied further,” he said. “Right now there is no drug that is Food and Drug Administration-approved for delirium. There is nothing out there.” Dr. Straker said he studied aripiprazole because it had not been tried for delirium and had the potential for fewer side effects than other antipsychotic agents. Hospital patients who develop delirium often have comorbidities, he said, presenting chart reviews of 21 patients with delirium.
In this unpublished series, he found that most had cardiovascular problems before treatment. Two-thirds had impaired glycemic control. Dyslipidemia, hypertension, and metabolic syndrome occurred in more than half. Nine were obese, and eight had QTc intervals greater than 450 milliseconds on their electrocardiograms.
“You might say in acute patients, why worry?” he challenged the audience, answering, “After delirium is resolved, we don't abruptly stop antipsychotics.” Many patients stay on antipsychotic medication long after leaving the hospital, according to Dr. Straker. Patients released to nursing homes may be kept on a drug for months before being reevaluated.
The 14 patients in the case series (eight women and six men) were 71 years old on average and had a mean score on the Clinical Global Impression (CGI) severity scale of 5.2. Dyslipidemia, hyperglycemia, hypertension, and metabolic syndrome were reported in more than half before treatment. Cardiovascular disease, cerebrovascular disease, and QTc prolongations were also reported but in a smaller proportion.
Dr. Straker said the etiology of delirium was varied. He cited medications, infection, surgery, dementia, and HIV as underlying factors. The average aripiprazole dose was 8.9 mg per day, with only two patients receiving more than 10 mg per day. Patients reached maximum treatment response in an average of 6.2 days, with a mean improvement of 2.1 on the CGI scale. Four patients had been given haloperidol during the first few days of their delirium.
Two patients died after discontinuing aripiprazole: one of sepsis, the other of respiratory failure after pneumonia. Among the adverse events that did not occur, Dr. Straker listed torsades de pointes, cardiac and cerebrovascular events, diabetic ketoacidosis, significant extrapyramidal effects or akathisia, dysphagia, and falls. He reported that average QTc decreased, with just one patient having it rise beyond 450 milliseconds. Fasting blood glucose fell from 176.1 mg/dL to 116.2 mg/dL, and no patient had a worsening of glycemic control.