Association Between Sedating Medications and Delirium in Older Inpatients
Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio.Journal of the American Geriatrics Society (Impact Factor: 4.57). 04/2013; 61(6). DOI: 10.1111/jgs.12253
OBJECTIVES: To examine the association between Beers criteria sedative medications and delirium in a large cohort of hospitalized elderly adults with common medical conditions. DESIGN: Retrospective cohort and nested case-control studies. SETTING: 374 U.S. hospitals. PARTICIPANTS: All individuals aged 65 and older admitted to the hospital between September 2003 and June 2005 with one of six principal diagnoses (acute myocardial infarction, chronic obstructive pulmonary disease, community-acquired pneumonia, congestive heart failure, ischemic stroke, urinary tract infection). MEASUREMENTS: Primary outcome was presumed hospital-acquired delirium, defined as initiation of an antipsychotic medication or restraints on hospital Day 3 or later. Logistic and proportional hazards regression were used to model the associations between sedative exposure and delirium. RESULTS: The dataset contained 225,028 participants (median age 82; 58% female). Four percent fit the definition of hospital-acquired delirium (median onset Day 5). In all, 38,883 (17%) participants received one or more sedative medications. In the cohort study, diphenhydramine (adjusted odds ratio (AOR) = 1.22, 95% confidence interval (CI) = 1.09-1.36) and short-acting benzodiazepines (AOR = 1.18, 95% CI = 1.03-1.34) were associated with greater risk of subsequent delirium. In the nested case-control study, diphenhydramine, short- and long-acting benzodiazepines and promethazine were associated with delirium. Amitriptyline and muscle relaxants were not associated with delirium in either study. Confounding by indication could not be excluded for drugs that are sometimes used improperly to treat delirium. CONCLUSION: An association was found between several Beers criteria sedative medications and delirium in hospitalized medical patients. Given the prevalence of these medications and the morbidity associated with delirium, further investigation into the appropriateness of such prescribing is warranted.
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ABSTRACT: Delirium is common in older adults in the perioperative period, being a complication in up to 60 % of major surgical procedures. Delirium has a significant impact on the medical, functional, and cognitive outcomes of older patients. Treatment of delirium can be quite complex and requires individualized patient assessment, plan of care, and empirical treatment. In light of the difficulties associated with delirium treatment and the complexity and frequent inadequacy of nonpharmacologic preventive measures, several drugs have been evaluated for efficacy in delirium prevention. We performed a literature review using Medline and the Cochrane Database for Systematic Reviews for randomized controlled trials, observational studies, and case reports evaluating pharmacologic treatments for prevention of delirium in older adults. Trials focused on patients with alcohol abuse were excluded. There is some preliminary evidence that haloperidol, newer neuroleptics (e.g., risperidone or olanzapine), and melatonin may be effective in reducing the incidence of postoperative delirium, but the data are not robust. Health care teams should still focus on traditional delirium prevention efforts, and reserve specific pharmacologic prevention to individual high-risk patients for whom the risks and benefits have been carefully considered.
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ABSTRACT: Anticholinergic and sedative medications are commonly used in older adults and are associated with adverse clinical outcomes. The Drug Burden Index was developed to measure the cumulative exposure to these medications in older adults and its impact on physical and cognitive function. This narrative review discusses the research and clinical applications of the Drug Burden Index, and its advantages and limitations, compared with other pharmacologically developed measures of high-risk prescribing.
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