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Rivastigmine in the treatment of delirium in older people: a pilot study

Published online by Cambridge University Press:  31 March 2010

Ross Overshott ,
Martin Vernon ,
Julie Morris  and
Alistair Burns
Ross Overshott*
Affiliation:
Department of Psychological Medicine, Royal Oldham Hospital, Oldham, U.K.
Martin Vernon
Affiliation:
University Hospital of South Manchester NHS Foundation Trust, Wythenshawe Hospital, Manchester, U.K.
Julie Morris
Affiliation:
University Hospital of South Manchester NHS Foundation Trust, Wythenshawe Hospital, Manchester, U.K.
Alistair Burns
Affiliation:
Faculty of Medical and Human Sciences, University of Manchester, U.K.
*
Correspondence should be addressed to: Dr Ross Overshott, Department of Psychological Medicine, L Block, Rochdale Road, Royal Oldham Hospital, OL1 2JH, U.K. Phone/Fax: +44 (0)161 6278330. Email: [email protected] or [email protected].
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Abstract

Background: Delirium is common in the elderly and is associated with high mortality and negative health outcomes. Reduced activity in the cholinergic system has been implicated in the pathogenesis of delirium. Cholinesterase inhibitors, which increase cholinergic activity, may therefore be beneficial in the treatment of delirium.

Methods: This is a double-blind, placebo-controlled randomized pilot study of the treatment of delirium with a cholinesterase inhibitor of patients admitted to hospital medical wards. Patients over the age of 65 years were identified as having delirium by the Confusion Assessment Method (CAM). Patients with delirium were randomized to receive rivastigmine 1.5 mg once a day increasing to 1.5 mg twice a day after seven days or an identical placebo (two tablets after seven days).

Results: Fifteen patients entered the trial; eight received rivastigmine and seven received placebo. All of the rivastigmine group, but only three of the placebo group, were negative for delirium on the CAM when they left the study and eventually discharged home. There was no significant difference in the duration of delirium between the two groups (rivastigmine group 6.3 days versus placebo group 9.9 days, p = 0.5, 95% confidence interval −15.6–8.4).

Conclusions: The numbers of patients who screened positive for delirium was very small and as a result the sample size was too small to make any meaningful inferences about treatment of delirium. Despite the small numbers included in the study, there are some indicators that rivastigmine may be safe and effective in treating delirium.

Keywords

acute confusioncholinesterase inhibitorselderlyclinical trial
Type
Research Article
Information
International Psychogeriatrics , Volume 22 , Issue 5 , August 2010 , pp. 812 - 818
Copyright
Copyright © International Psychogeriatric Association 2010

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References

American Psychiatric Association (1999). Practice guideline for the treatment of patients with delirium. American Journal of Psychiatry, 156 (Suppl.5), 1–20.Google Scholar
Cole, M. G. and Primeau, F. (1993). Prognosis of delirium in elderly hospitalized patients. Canadian Medical Association Journal, 149, 41–46.Google Scholar
Cole, M. G., Fenton, F. R., Engelsmann, F. and Mansouri, I. (1991). Effectiveness of geriatric psychiatry consultation in an acute care hospital: a randomized clinical trial. Journal of the American Geriatrics Society, 39, 1183–1188.CrossRefGoogle Scholar
Cole, M. G. et al. (2002). Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. Canadian Medical Association Journal, 167, 753–759.Google ScholarPubMed
Dautzenberg, P. L., Mulder, L. J., Olde Rikken, M. G., Wouters, C. J. and Loonen, A. J. (2004). Adding rivastigmine to antipsychotics in treatment of a chronic delirium. Age and Ageing, 33, 516–517. doi:10.1093/ageing/afh125.CrossRefGoogle ScholarPubMed
Folstein, M. F., Folstein, S. E. and McHugh, P. R. (1975). Mini-Mental State. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198.Google Scholar
Gamberini, M. et al. (2009). Rivastigmine for the prevention of postoperative delirium in elderly patients undergoing elective cardiac surgery: a randomized controlled trial. Neurologic Critical Care, 37, 1762–1768. doi:10.1097/CCM.0b013e31819da780.Google Scholar
Gill, S. et al. (2007). Antipsychotic drug use and mortality in older adults with dementia. Annals of Internal Medicine, 146, 775–786.CrossRefGoogle ScholarPubMed
Gleason, O. C. (2003). Donepezil for postoperative delirium. Psychosomatics, 44, 437–438.Google Scholar
Gottlieb, G. L., Johnson, J., Wanich, C. and Sullivan, E. (1991). Delirium in the medically ill elderly: operationalizing the DSM-III criteria. International Psychogeriatrics, 3, 181–196. doi:10.1017/S1041610291000650.Google Scholar
Han, L., McCusker, J., Cole, M., Abrahamowicz, M., Primeau, F. and Elie, M. (2001). Use of medication with anticholinergic effect predicts clinical severity of delirium symptoms of older medical inpatients. Archives of Internal Medicine, 161, 1099–1105. doi: 10.1001/archinte.161.8.1099.Google Scholar
Hshieh, T. T., Fong, T. G., Marcantonio, E. R. and Inouye, S. K. (2008). Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence. Journal of Gerontology, 63A, 764–772.Google Scholar
Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P. and Horwitz, R. I. (1990). Clarifying confusion: the confusion assessment method: a new method for the detection of delirium. Annals of Internal Medicine, 113, 941–948.CrossRefGoogle Scholar
Lipowski, Z. J. (1987). Delirium (acute confusional states). JAMA, 258, 1789–1792.CrossRefGoogle ScholarPubMed
Liptzin, B., Laki, A., Garb, J. L., Fingeroth, R. and Krushell, R. (2005). Donepezil in the prevention and treatment of post-surgical delirium. American Journal of Geriatric Psychiatry, 13, 1100–1106.Google Scholar
Lonergan, E., Britton, A. M., Luxenberg, J. and Wyller, T. (2007). Antipsychotics for delirium. Cochrane Database of Systematic Reviews, 3, CD005594.Google Scholar
Lundstrom, M., Edlund, A., Karlsson, S., Brännström, B., Bucht, G. and Gustafson, Y. (2005). A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. Journal of the American Geriatrics Society, 53, 622–628. doi: 10.1111/j.1532–5415.2005.53210.x.Google Scholar
Mach, J. R. Jr, Dysken, M. W., Kuskowski, M., Richelson, E., Holden, L. and Jilk, K. M. (1995). Serum anticholinergic activity in hospitalized older persons with delirium: a preliminary study. Journal of the American Geriatrics Society, 43, 491–495.Google Scholar
Maximer, S. M., Mellow, A. M. and Tandon, R. (1999). The efficacy, safety and tolerability of antipsychotics in the elderly. Journal of Clinical Psychiatry, 60 (Suppl. 8), 29–41.Google Scholar
Moretti, R., Torre, P., Antonello, R. M., Cattaruzza, T. and Cazzato, G. (2004). Cholinesterase inhibition as a possible therapy for delirium in vascular dementia: a controlled, open 24-month study of 246 patients. American Journal of Alzheimer's Disease and Other Dementias, 19, 333–339. doi: 10.1177/153331750401900607.CrossRefGoogle ScholarPubMed
Mussi, C., Ferrari, R., Ascari, S. and Salvioli, G. (1999). Importance of serum anticholinergic activity in the assessment of elderly patients with delirium. Journal of Geriatric Psychiatry and Neurology, 12, 82–86. doi: 10.1177/089198879901200208.CrossRefGoogle ScholarPubMed
Oldenbeuving, A. W., de Kort, P. L. M., Jansen, B. P. W., Kappellem, L. J. and Roks, G. (2008). A pilot study of rivastigmine in the treatment of delirium after stroke: a safe alternative. BioMedCentral, 8, 34. doi: 10.1186/1471-2377-8-34.Google Scholar
Sampson, E. L. et al. (2007). A randomized, double-blind, placebo-controlled trial of donepezil hydrochloride (Aricept) for reducing the incidence of postoperative delirium after elective total hip replacement. International Journal of Geriatric Psychiatry, 22, 343–349. doi: 10.1002/gps.1679.Google Scholar
Schneider, L. S., Dagerman, K. S. and Insel, P. (2005). Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA, 294, 1934–1943.CrossRefGoogle ScholarPubMed
Seitz, D. P., Gill, S. S. and van Zyl, L. T. (2007). Antipsychotics in the treatment of delirium: a systematic review. Journal of Clinical Psychiatry, 68, 11–21.CrossRefGoogle ScholarPubMed
Siddiqi, N., House, A. O. and Holmes, J. D. (2006). Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age and Ageing, 25, 350–364. doi:10.1093/ageing/afl005.Google Scholar
Trzepacz, P. T. (2000). Is there a final common neural pathway in delirium? Focus on acetylcholine and dopamine. Seminars in Clinical Neuropsychiatry, 5, 132–148. doi: 10.153/SCNP00500132.Google Scholar
Tune, E. (2000). Serum anticholinergic activity levels and delirium in the elderly. Seminars in Clinical Neuropsychiatry, 5, 149–153. doi: 10.153/SCNP00500149.Google Scholar
Wang, P. et al. (2005). Risk of death in elderly uses of conventional vs atypical antipsychotic medications. New England Journal of Medicine, 353, 2335–2341.Google Scholar
Wengel, S. P., Roccaforte, W. H. and Burke, W. J. (1998). Donepezil improves symptoms of delirium: implications for future research. Journal of Geriatric Psychiatry and Neurology, 11, 159–161.Google Scholar