October 2010

Exercise in Schizophrenia
Regular exercise can positively affect mental and physical health in people with schizophrenia.

Recognizing and Mitigating Delirium
Preventing delirium in hospitalized older patients saves lives and decreases dementia.

Lorcaserin: A New Drug for Weight Loss?
Lorcaserin has a better safety and adverse event profile but no greater efficacy than currently available weight loss agents.

In Brief
Bupropion during Pregnancy May Increase Risk of ADHD in Offspring; Bipolar Disorder Screening Recommended for Patients with Fibromyalgia

Treating Bipolar II Depression
Only quetiapine (Seroquel) is established as a first-line treatment for bipolar II depression; lithium, selective serotonin reuptake inhibitors (SSRIs), lamotrigine (Lamictal), and pramipexole (Mirapex and others) are second-line options.

Recognizing and Mitigating Delirium

October 2010

One way psychiatrists save lives in general hospitals is by identifying delirium. Data from a recent meta-analysis suggest that delirium in hospitalized patients 65 years and older doubles the risk of death and increases the risk of institutionalization more than twofold.1 Delirium is associated also with a more than 12-fold increase in the risk of dementia in this population. Prevalence studies have found that between 10% and 85% of hospitalized patients develop delirium, yet the condition often goes undiagnosed.2 One explanation is that clinicians treating critically ill patients commonly focus on vital organs to the exclusion of the brain. A consultation psychiatrist encourages the use of nurse-driven validated instruments that can detect delirium in as little as 30 seconds.

The ideal is to prevent delirium. Factors that increase the risk of delirium include infections, malnutrition, sleep deprivation, and medication withdrawal. Once delirium has been diagnosed, prompt management includes identifying the cause and avoiding measures that might exacerbate it. Even so, one study found that management of delirium did not improve long-term mortality or the need for institutional care.3 A psychiatrist quoted in the Journal of the American Medical Association observes that patients who have experienced delirium "will never be the same . . . not the way they were before."2

Choice of medication, especially which sedative or analgesic is used in elderly patients and others at risk to develop delirium, can be important. Dexmedetomidine (Precedex) is a sedative used in intensive care units (ICUs). An α2-receptor agonist, dexmedetomidine is notable for not causing respiratory depression. A few studies suggest that, compared with other drugs, such as benzodiazepines, it may reduce the incidence or duration of delirium.

Early mobilization of ICU patients also reduces the incidence of delirium and improves other functional outcomes. Such activity requires mental engagement and may help combat the variables that increase the likelihood, severity, and duration of delirium.

Experts in consultation psychiatry emphasize the importance of achieving a culture change in hospitals. A wide range of professionals who interact with patients must become aware of the signs and gravity of delirium and what to do when it occurs.

1Witlox J, Eurelings LSM, de Jonghe JFM, Kalisvaart KJ, Eikelenboom P, van Gool WA: Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: A meta-analysis. JAMA 2010;304:443-451.

2Kuehn BM: Delirium often not recognized or treated despite serious long-term consequences. JAMA 2010;304:389–395.

3Pitkälä KH, Laurila JV, Strandberg TE, Tilvis RS: Multicomponent geriatric intervention for elderly inpatients with delirium: A randomized controlled trial. J Gerontol A Biol Sci Med Sci 2006;61:176–181.