cl presentation vers 2.1

7/27/2019 CL Presentation Vers 2.1

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EBM Question C/L


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Delirium Definition

Delirium is a neuropsychiatric disordercharacterized by disturbances of

Consciousness

Attention

Cognition

Perception

With an abrupt onset and fluctuating course


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Delirium is Common

Delirium usually has an underlyingphysiological etiology

In a general hospital setting the occurrenceof Delirium may approach

30% in medically ill patients

40% in the hospitalized elderly

85% in cancer patients and for those withterminal illness


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APA Guidelines in the Treatment ofDelirium

(i) the identification of underlying etiologies

(ii) appropriate medical intervention to treatreversible etiologies

(iii) initiation of environmental interventionsto provide safety and support

(iv) relief of distressing symptomswith antipsychotics


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Antipsychotic Delirium TreatmentRecommendations @ URMC

Haldol (IV or PO) Has historically been the treatment for delirium

Seroquel Ideally Treats delirium and provides sedation without significant

EPS

Abilify (once patient was already onAbilify)


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Case

Patient with bipolar d/o presenting withhyperactive delirium (but not in a manicepisode).

Was on Abilify 15 mg

Recommendation go up to 20 mg

Patient improved clinically


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Intriguing case?

Somewhat surprised the intervention ofincreasing Abilify from 15 mg to 20 mgworked

Lack of experience using or hearing aboutAbilify (specifically) used for delirium


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Intriguing case?

Abilify differs from all other antipsychoticsby being a partial agonist (not a D2blocker). . .

Mechanism by which antipsychotics treatdelirium unclear

By being a partial D2 agonist could there bea difference could there be a difference inefficacy for treating delirium?


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PICO Question

Patient population: Delirious patients

Intervention: Abilify

Comparison: Other antipsychotics (non partial

agonists either FGA or SGA)

Outcome: Resolution of Delirium

In patients with delirium, is Abilify as effective asother anti-psychotics in clearing the delirium?


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Article

Aripiprazole and haloperidol in thetreatment of delirium

Soenke Boettger , Miriam Friedlander, William Breitbart

Australian and New Zealand Journal of Psychiatry 2011; 45:477 482


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Article Aim

To further explore the efficacy andtolerability of Abilify (as compared withHaldol) in the treatment of delirium

Previous studies on this topic include a singlepublished case series and two published casereports examining the safety & tolerability of

Abilify Results from these studies showed a significant

reduction in symptoms of delirium


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Methods

This paper performed a secondary analysison patients with delirium who received

Abilify and then compared this data to a

case matched sample of subjects treatedwith Haldol.

Retrospective chart review

Essentially they compared reduction inMDAS scores between Haldol / Abilify.


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MDAS - Memorial DeliriumAssessment Scale

10-item, four-point (0-3), clinician-rated scaleThe MDAS items reflect the diagnostic criteria for

delirium in the DSM-IV-TR and assess disturbancein arousal and level of consciousness, cognitive

functioning (memory, attention, orientation, andperceptual disturbances) and psychomotoractivity.

MDAS scores greater than 10 identified the

presence of deliriumMDAS scores of less than 10 indicated the

resolution of delirium in this analysis


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Limitations

Paper based on retrospective analysis of prospectivelycollected data (Level 4 Evidence).

Selection of neuroleptic based on psychiatrists preference

Severely agitated patients were excluded from the analysis

21 Patients in each medication group (not a large analysis)

This paper acknowledged the need for further randomized,double blind, controlled studies.


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Evidence Based Strength

Quality Type of Evidence 1a Systematic review of RCTs 1b Individual RCT (with narrow

confidence interval) 2a Systematic review of cohort

studies 2b Individual cohort study 3 Case control studies4 Case Series (retrospective

chart review) 5 (Worst) Expert Opinion, Editorials


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Strengths

Authors attempted to case match patientstreated with Abilify to those treated withHaldol with both groups having similar:

Age

Initial MDAS Scores

Similar etiologies of delirium

Similar ratios of subtypes of delirium:Hypoactive / hyperactive delirium were


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Strengths

Analysis was not sponsored by apharmaceutical company.

Although some of the authors had received

grants from companies such as Lilly andPurdue-Pharma none reported affiliations toBristol-Myers Squibb(Abilify pharmaceuticalcompany)

The authors alone are responsible for thecontent and writing of the paper.


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Analysis MDAS Scores

Abilify

Time 1: 18.1

Time 2: 10.8

Time 3: 8.3

Haldol

Time 1: 19.9

Time 2: 9.9

Time 3: 6.8***No significant difference in MDAS scores ***

At times 2 and times 3

Time 2: 48 72 h later

Time 3: 7 days later

Time 2: 48 72 h later

Time 3: 7 days later


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Analysis of Safety: Side effects

Abilify none

Haldol EPS (parkinsonism and dystonia).More likely at higher doses


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Article Conclusions

There was no significant difference in theability of Abilify to ameliorate the symptomsof delirium more effectively than haloperidol

at time points T2 and T3 in either subtypeof delirium, hypoactive or hyperactive.

OR

Abilify may be as effective as haloperidol inthe management of delirium and itssubtypes


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Article Conclusions

Abilify demonstrated an advantage intolerability by the absence of extrapyramidalside effects.

This article alluded to the conclusion thatAbilify, in general, is a better choice over Haldolsimply because it has less incidence of EPS.


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My Conclusions

At this time given the available evidence (althoughof lower grade) it seems reasonable to believethat Abilify and Haldol likely have relatively similar

efficacies in treating delirium. However, moreresearch is needed.

Again noting: this study was not strong enough toconclude this definitively (it was not a superiority trial,

equivalence trial, a non-inferiority trial OR even a trial atall [it was a retrospective chart review])


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