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10 What is the best way to manage delirium? a systematic review of the evidence
  1. Lori Black,
  2. Hugh Rickards

Abstract

Objective Delirium is a transient acute confusional state which can have long-term neurological sequelae. The purpose of this systematic review is to investigate the best ways to manage delirium from a pharmacological and non-pharmacological perspective.

Method I followed the PRISMA guidelines to conduct a systematic review, using Medline, Embase and PsycInfo to search for literature. I searched for “delirium” and then “manag*” OR “treat*” OR “pharm*” OR “non-pharm*” OR “interven*” OR “care” or “psych*”, combining these searches with AND. This gave 5215 search results, which was refined to 4359 search results by including on English articles with abstracts. By reading the titles I was left with 43 results to be looked at more closely by reading the abstract. This was reduced to 21 on reading those abstracts.

Results 13 studies looked at the efficacy of atypical antipsychotics in treating delirium, usually comparing them with haloperidol, other atypical antipsychotics or with a placebo. Most of these studies found atypical antipsychotics as effective as haloperidol. All atypical antipsychotics appeared equally efficacious. Most articles found that atypical antipsychotics were safe for use in delirium, with few associated adverse events.

Some studies looked at the effect of place of treatment on delirium resolution. Here, patients responded better when treated on wards offering holistic, specialist geriatric care. Pitkala et al. (2006) found that such patients were more likely to receive acetylcholinesterase inhibitors and atypical antipsychotics than other pharmacological options and overall had fewer psychotropic drugs.

Conclusion The articles reviewed in this study predominantly had small sample sizes. Just one study looked purely at non-pharmacological care for delirium, finding it was effective. Very few studies compared the efficacy and safety of psychoactive drugs to that of placebo, preferring to compare them with each other.

The findings of this systematic review indicate that patients with delirium are best managed on geriatric wards where they will be given individually tailored treatment. The one article reviewed investigating non-pharmacological management of delirium suggests that this may also be a useful method of treating of delirium.

Our findings suggest that atypical antipsychotics are equally effective as typical antipsychotics, such as haloperidol. These may also be safer than previously thought but there is insufficient evidence to determine whether pharmacological treatment of delirium is actually safe.

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