INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 35(4) 429-433, 2005
ARIPIPRAZOLE IN THE TREATMENT
ADEKOLA O. ALAO, M.D., MRCPSYCH
MAUREEN SODERBERG, M.D.
ELYSSA L. POHL, B.A.
MARVIN KOSS, M.D.
SUNY Upstate Medical University, Syracuse, New York
Objective: Delirium is a common condition frequently seen in consultation-
liaison psychiatry. It is especially common among medically compromised
is associated with a higher morbidity, mortality, and longer hospitalization.
Traditionally, haloperidol has been used to treat agitation as it may occur in
delirium. However, atypical antipsychotics are being increasingly used to
treat delirium. Method: In this article, we will describe two cases of delirium
successfully treated with aripiprazole. Results: Both patients had significant
improvement in their delirium as measured by the delirium rating scale.
Conclusion: Aripiprazole appears to be effective in reducing the symptoms of
(Int’l. J. Psychiatry in Medicine 2005;35:429-433)
Key Words: aripiprazole, delirium, atypical, antipsychotics, neuroleptics
Delirium is a common condition that occurs in the presence of a major medical
illness. It is an acute fluctuating condition that affects the patient’s attention and
? 2005, Baywood Publishing Co., Inc.
cognitive function. It is also associated with increased morbidity, mortality, as
well as longer hospitalizations. The symptoms of delirium consist of delusions,
hallucinations, confusion, and disorientation. Traditionally, haloperidol has been
the drug of choice in the treatment of delirium . However, haloperidol has been
associated with serious adverse effects including extra-pyramidal side effects,
tardive dyskinesia, and neuroleptic malignant syndrome . We will report on the
use of aripiprazole in the treatment of delirium. To the best of our knowledge, this
is the first published report of such an intervention.
The patient, M.I., is a 65-year-old African-American male with no previous
psychiatric history. However, the patient did have a medical history of hyper-
tension, diabetes mellitus, and diabetic nephropathy with resulting chronic
renal failure treated with dialysis three times a week. He has a history of
non-compliance with his dialysis. The patient was admitted to the emergency
room after complaining of lethargy, disorientation, and confusion. He had missed
his dialysis two times in a row and came in with electrolyte abnormalities. He
was admitted to the intensive care unit for correction of those abnormalities.
While in the ICU, he was found to be disoriented to time and place, have visual
and tactile hallucinations, as well as physical aggression toward the nursing staff.
A psychiatric consultation was obtained to evaluate the change in mental status,
as well as to assist in managing the patient. An evaluation of the patient’s capacity
The patient denied any prior psychiatric history. He was disoriented to time,
place, and person with significant cognitive deficits (lack of attention and con-
centration.) On the mini-mental state examination (MMSE) he scored a 5 out of
a total of 30 and scored 28 on the delirium rating scale (DRS.) The patient was
deemed to lack capacity and diagnosed with delirium secondary to electrolyte
imbalance resulting from chronic renal failure. He was started on aripiprazole
30 mg po qhs. In addition, consent for dialysis was obtained from his next
of kin. The patient was followed on a daily basis. By the seventh day, the
patient was alert and oriented. His MMSE score increased to 28 and his DRS
score reduced to 6. Aripiprazole was continued for another 10 days and then
discontinued. After the patient fully recovered, he was subsequently discharged
to the outpatient clinic.
The patient, B.F. is a 37-year-old Native American female with a history of
alcohol dependency. The patient was admitted to the emergency room after
experiencing a grand mal seizure, presumably related to alcohol withdrawal.
430/ALAO ET AL.
Psychiatry consultation was obtained after the patient was found to have
confusion, agitation, experiencing visual hallucinations (bugs crawling all over
the wall), and autonomic instability. A diagnosis of alcohol withdrawal delirium
was made based on the clinical findings.
The patient was unable to give a coherent history because of her significant
confusion. However, collateral information from her husband revealed a sig-
nificant history of alcohol consumption. She drank about a quart of vodka
every day, and had been drinking for several years. She had been in alcohol
rehabilitation programs three times in the past but would always relapse after
discharge. She had no other previous psychiatric history. Her last drink was
two days prior to presentation.
Mental status exam revealed a disheveled American who looked significantly
older than her stated age. She was disoriented to time, place, and person and was
responding to internal stimuli. She had marked disturbances in her concentration
and attention. She scored a 7 out of a total score of 30 on the MMSE and 18 on the
DRS. A diagnosis of delirium secondary to alcohol withdrawal was made, and the
patient was started on IV lorazepam 2 mg q 4 hours. Aripiprazole 15 mg po qhs
was added at the same time to control her agitation and confusion. In addition, she
was given parenteral thiamine and oral folic acid. The dose of lorazepam was
gradually titrated down over the next two weeks. The patient progressively
improved and on day seven her MMSE increased to 27 and her DRS decreased
to 6. At this time, aripiprazole was discontinued. The patient was subsequently
transferred to an inpatient alcohol rehabilitation unit.
Delirium is an acute condition that causes a disturbance of consciousness
with the reduced ability to focus, sustain or shift attention, as well as a change in
cognition. The cognitive disturbances can include having memory problems,
disorientation, and language disturbances. There can also be perceptual abnor-
malities such as auditory and, more commonly, visual and tactile hallucinations.
Since delirium is essentially a manifestation of an underlying medical or
surgical illness, the treatment of delirium should primarily involve treating the
disturbances of consciousness and perceptual abnormalities, high potency anti-
psychotics are an invaluable adjunctive treatment. Traditionally, haloperidol
has been the gold standard in treatment of delirium; however, in the early 1990s,
the new generation of atypical antipsychotics were introduced. The mechanism
of action of these antipsychotics involves preferential serotonergic (5HT2a)
blockade and selective dopamine D2 blockade. This has resulted in a significantly
lower rate of extra-pyramidal adverse effects. These atypical antipsychotics
have been found to be effective and better tolerated than typical antipsychotics
ARIPIPRAZOLE IN THE TREATMENT OF DELIRIUM/431
in the treatment of schizophrenia and bipolar II disorder. However, their use in
delirium has not been systematically studied and no atypical antipsychotics have
The atypical antipsychotics that have been described as efficacious in delirium
include risperidone , olanzapine , quetiapine , and ziprasidone . To
date, there are no published studies utilizing aripiprazole to treat delirium.
Aripiprazole is the sixth second generation antipsychotic recently approved
by the Food and Drug Administration for the treatment of schizophrenia.
Aripiprazole is considered a partial dopaminergic agonist, acting on both post-
synaptic dopamine 2 receptors and pre-synaptic autoreceptors. In addition, it
displays partial agonism at serotonin 1a receptors and antagonism at serotonin 2a
receptors . It is thus hypothesized to improve both the positive and negative
symptoms of schizophrenia. Clinical studies have shown aripiprazole is well
tolerated among patients with schizophrenia . In this article, we described the
successful treatment of two patients with delirium using aripiprazole. Among
other factors, the choice of an anti-psychotic should include efficacy and adverse
reporting any adverse effects other than sedation.
in the treatment of agitation and confusion in patients suffering from delirium.
It should be noted that in both cases, the underlying medical condition was
treated, as is expected in all cases of delirium. Since this is only a report of two
cases, further case reports and controlled studies will be necessary to understand
the role of aripiprazole in the treatment of delirium.
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Direct reprint requests to:
Adekola O. Alao, M.D.
Division of Consultation–Liaison Psychiatry
Department of Psychiatry
SUNY Upstate Medical University
750 East Adams Street
Syracuse, NY 13210
ARIPIPRAZOLE IN THE TREATMENT OF DELIRIUM/ 433