Critical Illness: Haloperidol and Ziprasidone for Treatment of Delirium

MedicalResearch.com Interview with:

Brenda Truman Pun, DNP, RN Program Clinical Manager Vanderbilt University Medical Center

Dr. Truman Pun

Brenda Truman Pun, DNP, RN
Program Clinical Manager
Vanderbilt University Medical Center

MedicalResearch.com: What is the background for this study?

Response: Delirium is a serious problem in Intensive Care Units around the world. Approximately 80% of mechanically ventilated patients develop delirium, acute confusion, while in the ICU. Once thought to be a benign side effect of the ICU environment, research now shows that delirium is linked to a myriad of negative outcomes for patients which include longer ICU and Hospital stays, prolonged time on the ventilator, increased cost, long-term cognitive impairment and even mortality. For a half a century clinicians have been using haloperidol, an typical antipsychotic, to treat delirium in the ICU. However, there has never been evidence to support the use of haloperidol or its pharmacologic cousins, the atypical antipsychotics, to treat delirium. These drugs have serious side effects that include heart arrhythmias, muscle spasms, restlessness and are associated with increased mortality when given for prolonged periods in the outpatient settings leading to a black box warning for their use in this setting.

The MIND-USA study was a double blind placebo controlled trial which evaluated the efficacy and safety of antipsychotics (i.e., haloperidol and ziprasidone) in the treatment delirium in adult ICU patients.   Continue reading

Do Antipsychotics Shorten Duration of Delirium in ICU Patients?

MedicalResearch.com Interview with:

Eugene Wesley Ely, M.D. Dr. E. Wesley Ely is a Professor of medicine at Vanderbilt University School of Medicine with subspecialty training in Pulmonary and Critical Care Medicine.

Dr. Ely
Photo: Anne Rayner, VU

Eugene Wesley Ely, M.D.
Dr. E. Wesley Ely is a Professor of medicine at Vanderbilt University School of Medicine with subspecialty training in Pulmonary and Critical Care Medicine. 

MedicalResearch.com: What is the background for this study?

Response: Critically ill patients are not benefitting from antipsychotic medications that have been used to treat delirium in intensive care units (ICUs) for more than four decades, according to a study released today in the New England Journal of Medicine.

Each year, more than 7 million hospitalized patients in the United States experience delirium, making them disoriented, withdrawn, drowsy or difficult to wake.

The large, multi-site MIND USA (Modifying the INcidence of Delirium) study sought to answer whether typical and atypical antipsychotics — haloperidol or ziprasidone —affected delirium, survival, length of stay or safety.

Researchers screened nearly 21,000 patients at 16 U.S. medical centers. Of the 1,183 patients on mechanical ventilation or in shock, 566 became delirious and were randomized into groups receiving either intravenous haloperidol, ziprasidone or placebo (saline).

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Dexmedetomidine Reduced Risk of Delirium

MedicalResearch.com Interview with:

Yoanna Skrobik MD FRCP(c) MSc McGill University Health Centre Canada

Dr. Skrobik

Yoanna Skrobik MD FRCP(c) MSc
McGill University Health Centre
Canada

MedicalResearch.com: What is the background for this study?

Response: My clinical research interests revolve around critical care analgesia, sedation, and delirium. I validated the first delirium screening tool in mechanically ventilated ICU patients (published in 2001), described ICU delirium risk factors, associated outcomes, compared treatment modalities and described pharmacological exposure for the disorder. I was invited to participate in the 2013 Society of Critical Care Medicine Pain, Anxiety, and Delirium management guidelines, and served as the vice-chair for the recently completed Pain, Agitation, Delirium, Early Mobility and Sleep upcoming guidelines.

Until this study, no pharmacological prevention or intervention could convincingly be considered effective in ICU delirium. Although Haloperidol and other antipsychotics are frequently used in practice, their lack of efficacy and possible disadvantages are increasingly being understood.

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Study Finds No Benefit To Prophylactic Haldol For Delirium in ICU

MedicalResearch.com Interview with:
“hospital.” by Bethany Satterfield is licensed under CC BY 2.0
Mark van den Boogaard, PhD, RN, CCRN
Assistant Professor
Department of Intensive Care Medicine
Radboud University Medical Center
Nijmegen Netherlands 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response:  Delirium is affecting many of our intensive care unit (ICU) patients which is impacting their recovery on the short-term as well as on the long-term. Therefore we were very interested to investigate if the use prophylactic haloperidol would be beneficial for the ICU patients. Especially because there were indications that it would be effective in ICU delirium prevention and also because this drug is being used in daily practice to prevent ICU delirium although there is no clear evidence. The overall finding of our large-scale well designed study is that we didn’t find any beneficial effect of prophylactic haloperidol in ICU patients. Moreover, this finding is very consistent over all groups of patients.  Continue reading

Modified Hospital Elder Life Program Reduces Post-Op Delirium and Length of Stay

MedicalResearch.com Interview with:
Cheryl Chia-Hui Chen, RN, DNSc

Vice Dean for Student Affairs
Professor of Nursing
National Taiwan University
Nurse Supervisor at National Taiwan University Hospital
Taipei, Taiwan

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Older patients undergoing abdominal surgery often experience preventable delirium, which greatly influences their postoperative recovery and hospital length of stay. The modified Hospital Elder Life Program (mHELP) utilizes nurses to reduce postoperative delirium and LOS among older patients undergoing abdominal surgery for resection of malignant tumor. The mHELP consisted of 3 protocols: oral and nutritional assistance, early mobilization, and orienting communication, researchers say.

Researchers at the National Taiwan University Hospital randomly assigned 377 patients undergoing abdominal surgery for a malignant tumor to an intervention (n = 197) or usual care (n = 180).

Postoperative delirium occurred in 6.6 percent of mHELP participants vs 15.1 percent of control individuals (odds of delirium reduced by 56 percent). Intervention group participants received the mHELP for a median of 7 days, and they had a median LOS that was two days shorter (12 vs 14 days).

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Does Melatonin Prevent Delirium In Elderly Surgery Patients?

Annemarieke de Jonghe Academic Medical Center University of Amsterdam Departement of Internal Medicine Section of Geriatric Medicine F4-218 Amsterdam, The NetherlandsMedicalResearch.com Interview with:
Annemarieke de Jonghe
Academic Medical Center
University of Amsterdam
Departement of Internal Medicine
Section of Geriatric Medicine F4-218
Amsterdam, The Netherlands

Medical Research: What are the main findings of the study?

Dr. de Jonghe: We investigated the preventive properties of melatonin versus placebo in a prospective cohort of elderly hip fracture patients (n=378). We found that 3mg melatonin vs placebo, given for 5 days from the day of admission, did not influence the incidence of delirium. However, in a posthoc analysis we found that more patients in the placebo group more often had a longer lasting delirium.

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Delirium: New Scoring System Relates Severity To Hospital Outcomes

Sharon K. Inouye, MD, MPH Professor of Medicine, Harvard Medical School Director, Aging Brain Center, Institute for Aging Research Hebrew SeniorLife both in Boston, MAMedicalResearch.com Interview with:
Sharon K. Inouye, MD, MPH
Professor of Medicine, Harvard Medical School
Director, Aging Brain Center, Institute for Aging Research
Hebrew SeniorLife both in Boston, MA

Study Co- Authors Cyrus Kosar, Douglas Tommet, Eva Schmitt, Margaret Puelle, Jane Saczynski, Edward Marcantonio and Richard Jones. 

MedicalResearch.com: What are the main findings of the study? 

Dr. Inouye: In this study, we developed and validated a new scoring system for delirium severity.  Delirium (acute confusional state) is a common and morbid complication of hospitalization for older persons, which often goes undetected.  Our new scoring system indicates that the severity of delirium is directly related to hospital outcomes, such as length of stay, nursing home placement, death, and healthcare costs.
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Emergency Room Screening for Delirium

Dr. Michael A. LaMantia Regenstrief Institute, Inc. Investigator and Assistant Professor of Medicine Indiana University School of MedicineMedicalResearch.com Interview with:
Dr. Michael A. LaMantia
Regenstrief Institute, Inc. Investigator and
Assistant Professor of Medicine
Indiana University School of Medicine

MedicalResearch.com: What are the main findings of the study?

Dr. LaMantia: We conducted a systematic review of existing studies on delirium in emergency departments and found that neither completely validated delirium screening instruments nor an ideal schedule to perform delirium assessments exist there.
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Delirium Prediction Rule: the AWOL Tool

MedicalResearch.com Interview with:

Vanja Douglas, MD Sara & Evan Williams Foundation Endowed Neurohospitalist Chair Assistant Professor of Clinical Neurology UCSF Department of Neurology Neurology Clerkship Director Editor in Chief, The NeurohospitalistVanja Douglas, MD
Sara & Evan Williams Foundation
Endowed Neurohospitalist Chair
Assistant Professor of Clinical Neurology
UCSF Department of Neurology
Neurology Clerkship Director
Editor in Chief, The Neurohospitalist

MedicalResearch.com: What are the main findings of the study?

Answer: The study found that a simple 2-minute assessment performed at the time of hospital admission can accurately predict an adult medical inpatient’s risk of developing delirium during that hospitalization.
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