Winter 2013 – Can Donepezil Hydrochloride Reduce the Role of Neuroleptic Drugs in Delirium? A Case Report
Can Donepezil Hydrochloride Reduce the Role of Neuroleptic Drugs in Delirium? A Case Report.
Lloyd D Hughes*, Emily McKay.
Medical School, Liverpool University, Liverpool, England
*Corresponding author: Lloyd D. Hughes; L.D.Hughes[at]dundee.ac.uk
Key Words: geriatrics; delirium; psychiatry; acetylcholinesterase inhibitors.
Background: Recent evidence shows that a confirmed diagnosis of delirium increases both patient morbidity and mortality. Importantly, these increases are independent of patient age, and presence of co-morbid disease. In the last few years, there has been evidence that acetylcholinesterase inhibitors may have a limited role in managing episodes of mild/moderate delirium. Methods: This case study reports a patient whose behavioral disturbances caused by delirium, responded well to donepezil hydrochloride in a nursing home in Dundee, United Kingdom. Results:Our clinical case focuses on a patient who was diagnosed with a mixed picture delirium after developing PUO. This case report notes that Mr A, a patient already prescribed donepezil hydrochloride, saw an improvement in his behavioral symptoms after an increase in his dose. This enabled the patient to avoid receiving neuroleptic or benzodiazepine medication, known to be particularly problematic in older patients.
Conclusion: The authors tentatively propose that patients in community care already prescribed acetylcholinesterase inhibitors, may benefit from an increased dose in cases of mild delirium (where there is no clear cause or requirement for hospital admission). In line with the significant impact that delirium has upon older patients in community care, we would call for further studies looking at the influence that these medications may have on the sequelae of delirium in patients in the community.
Published: February 27, 2013
Senior Editor: Skyler Johnson
Junior Editor: Bobby Gambhir
Hughes LD, McKay E. Can Donepezil Hydrochloride Reduce the Role of Neuroleptic Drugs in Delirium? A Case Report. Medical Student Research Journal. 2013;2(Winter):11-16.
Can donepezil hydrochloride reduce the role of
neuroleptic drugs in delirium? A case report
1. Fields SD. Delirium predicts 12-month mortality independent of dementia status. ACP J Club. 2003; 139(3):80. http://www.ncbi.nlm.nih.gov/pubmed/14594431.
2. Alagiakrishnan K, Blanchette P. Delirium; 2012. Available from: http://emedicine.medscape.com/article/288890-overview [cited 28 October 2012].
3. Cerejeira J, Taylor JP. Diagnosing, treating and preventing delirium. Geriatr Med. 2011; 41(2):81-5. http://www.gmjournal.co.uk/uploadedfiles/redbox/pavilion_content/our_content/social_care_and_health/gm_archive/2011/february/feb2011p81.pdf
4. Curran S, Wattis J. Delirium and the elderly patient. Geriatr Med. 2007; 37(11):35-40. https://www.gmjournal.co.uk/uploadedFiles/Redbox/Pavilion_Content/Our_Content/Social_Care_and_Health/GM_Archive/2007/November/Nov07p35.pdf
5. Inouye SK. Delirium in older persons. NEJM. 2006; 345:1157-65. http://dx.doi.org/10.1056/NEJMra052321.
6. Boorsma M, Joling KJ, Frijters DH, Ribbe ME, Nijpels G, van Hout JP. The prevalence, incidence and risk factors for delirium in Dutch nursing homes and residential care homes. Int J Geriatr Psychiatry. 2011; 26(7):711-22. http://dx.doi.org/10.1002/gps.2770.
7. Hughes LD, Witham MD, MacLullich A. Delirium in older patients: important determinant of hospital outcome. J Indian Acad Geriatr. 2012; 8(2):92-4. http://sumj.dundee.ac.uk/data/uploads/delirium-jiag.pdf
8. Wass S, Webster PJ, Nair BR. Delirium in the elderly: a review. Oman Med J. 2008; 23(3):150-7. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3282320/
9. McCusker J, Cole M, Dendukuri N, Han L, Belzile E. The course of delirium in older medical inpatients: a prospective study. J Gen Intern Med. 2003; 18:696704. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1494920/
10. Tune LE, Egeli S. Acetylcholine and delirium. Dement Geriatr Cogn Disord. 1999; 10(5):342-4. http://dx.doi.org/10.1159/000017167.
11. Hughes LD, Mthembu M, Adams L. Diagnostic work-up and treatment of Dementia. Geriatr Med. 2011; 41(11):595-600. http://sumj.dundee.ac.uk/data/uploads/dementia.pdf
12. GP Training Website. Mini-mental state examination. Available from: http://www.gptraining.net/protocol/psychiatry/mini_mental_state.htm [cited 28 October 2012].
13. Waszynski CM. Confusion assessment method (CAM). Best practices in nursing care to older adults. Try This. 2001; 13(11):1-2. http://consultgerirn.org/uploads/File/trythis/try_this_13.pdf
14. NHS Tayside Website. Tayside area formulary. 2010. Available from: http://www.nhstaysideadtc.scot.nhs.uk/TAPG%20html/MAIN/Front%20page.htm [cited 28 October 2012].
15. National Institute for Health and Clinical Excellence (2010). Delirium: diagnosis, prevention and cure. London: National Institute for Health and Clinical Excellence. Available From http://www.nice.org.uk/
16. Litvin CB, Ornstein SM, Wessell AM, Nemeth LS , Nietert PJ. Adoption of a clinical decision support system to promote judicious use of antibiotics for acute respiratory infections in primary care. Int J Med Inform. 2012; 81(8):521-6. http://dx.doi.org/10.1016/j.ijmedinf.2012.03.002.
17. Posner JD. Particular problems of antibiotic use in the elderly. Geriatrics. 1982; 37(8):49-54. http://www.ncbi.nlm.nih.gov/pubmed/7095428
18. Guthrie B, Clark SA, McCowan C. The burden of psychotropic drug prescribing in people with dementia: a population database study. Age Ageing 2010; 39(5):637-42. http://dx.doi.org/10.1093/ageing/afq090.
19. Hughes LD, Hanslip J, Witham MD. Centrally active prescribing for nursing home residents how are we doing? Eur Geriatric Med. 2012; 3(5):304-7. http://dx.doi.org/10.1016/j.eurger.2012.04.008.
20. Banerjee S. Report for the minister of state for care services: the use of antipsychotic medication for people with dementia; 2009. Available from: http://www.nhs.uk/news/2009/10October/Pages/Antipsychotic-use-in-dementia.aspx
[cited 28 October 2012].
21. MacLullich AM, Beaglehole A, Hall RJ, Meagher DJ. Delirium and long-term cognitive impairment. Int Rev Psychiatry. 2009; 21(1):30-42. http://dx.doi.org/10.1080/09540260802675031.
22. Himmelheber AM, Sarter M, Bruno JP. Increases in cortical acetylcholine release during sustained attention performance in rats. Cogn Brain Res. 2000; 9(3):313-25. http://dx.doi.org/10.1016/S0926-6410(00)00012-4.
23. Ehrenstein G, Galdzicki Z, Lange GD. The choline-leakage hypothesis for the loss of acetylcholine in Alzheimer’s disease. Biophys J. 1997; 73(3):1276-80. http://dx.doi.org/10.1016/S0006-3495(97)78160-8.
24. Francis PT, Palmerb AM, Snapeb M, Wilcock GK. The cholinergic hypothesis of Alzheimer’s disease: a review of progress. J Neurol Neurosurg Psychiatry. 1999; 66:137-47. http://dx.doi.org/10.1136/jnnp.66.2.137.
25. Birks J. Cholinesterase inhibitors for Alzheimer’s disease. Cochrane Database Syst Rev. 2006; 25(1):CD005593. http://dx.doi.org/10.1002/14651858.CD005593.
26. National Institute for Health and Clinical Excellence (2011). Dementia supporting people with dementia and their careers in health and social care’ [incorporating NICE technology appraisal of drugs for Alzheimer’s disease]. London: National Institute for Health and Clinical Excellence. Available from http://www.scie.org.uk/publications/misc/dementia/dementia-guideline.pdf
27. Moretti R, Torre P, Antonello RM, Cattaruzza T, Cazzato G. Cholinesterase inhibition as a possible therapy for delirium in vascular dementia: a controlled, open 24-month study of 246 patients. Am J Alzheimers Dis Other Demen. 2004; 19(6):333-9. http://dx.doi.org/10.1177/153331750401900607.
28. Oldenbeuving AW, de Kort PL, Jansen BP, Kappelle LJ, Roks G. A pilot study of rivastigmine in the treatment of delirium after stroke: a safe alternative. BMC Neurol. 2008; 8:34. http://dx.doi.org/10.1186/1471-2377-8-34.
29. Gamberini M, Bolliger D, Lurati B, et al. Rivastigmine for the prevention of postoperative delirium in elderly patients undergoing elective cardiac surgery – a randomized controlled trial. Crit Care Med. 2009; 37:1762-8. http://dx.doi.org/10.1097/CCM.0b013e31819da780.
30. Cerejeira J, Batista P, Nogueira V. Low preoperative plasma cholinesterase activity as a risk marker of post-operative delirium in elderly patients. Age Ageing. 2011; 40(5): 621-6. http://dx.doi/org/10.1093/ageing/afr053.
31. van Eijk MMJ, Roes KCB, Honing MLH, et al. Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients: a multicentre, double-blind, placebo-controlled randomized trial. Lancet. 2010; 376:1829-37. http://dx.doi.org/10.1016/S0140-6736(10)61855-7.
32. de Pont AC, van Geer MA, Schultz MJ. Cholinesterase inhibitor treatment in patients with delirium. Lancet. 2011; 377(9769):899. http://dx.doi.org/10.1016/S0140-6736(11)60342-5.
33. Frölich L, Forstl H. Cholinesterase inhibitor treatment in patients with delirium. Lancet. 2011; 377(9769):899. http://dx.doi.org/10.1016/S0140-6736(11)60341-3.
34. MacLullich AM, Hall RJ. Who understands delirium? Age Ageing. 2011; 40(4):412-4. http://dx.doi.org/10.1093/ageing/afr062.
35. MacLeod AD. Delirium: the clinical concept. Palliat Support Care. 2006; 4(3):305-12. http://dx.doi.org/10.1017/S147895150606038X.
36. British Geriatric Society. Guidelines for the prevention, diagnosis and management of delirium in older people in hospital; 2006. Available from: http://www.bgs.org.uk [cited 28 October 2012].
37. Mason N, Fletcher P. Assessment of a confused patient. Geriatr Med. 2012; 42(10):41-5. http://www.gmjournal.co.uk/uploadedfiles/redbox/pavilion_content/our_content/social_care_and_health/gm_archive/2012/october/gmoct2012p41.pdf
38. Maclullich AM, Ferguson KJ, Miller T, de Rooij SE, Cunningham C. Unravelling the pathophysiology of delirium: a focus on the role of aberrant stress responses. J Psychosom Res. 2008; 65(3):229-38. http://dx.doi.org/10.1016/j.jpsychores.2008.05.019.
39. Van der Mast RC, Fekkes D. Serotonin and amino acids: partners in delirium pathophysiology? Semin Clin Neuropsychiatry. 2000; 5(2):125-31. http://www.ncbi.nlm.nih.gov/pubmed/10837101
40. Pandharipande PP, Morandi A, Adams JR, et al. Plasma tryptophan and tyrosine levels are independent risk factors for delirium in critically ill patients. Intensive Care Med. 2009; 35(11):1886-92. http://dx.doi.org/10.1007/s00134-009-1573-6.
41. Shahid A, Milapkumar P, Shagufta J, et al. Insight into delirium. Innov Clin Neurosci. 2011; 8(10):25-34. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3225129/
Latest posts by Kevin Patterson (see all)
- Elective ’14 First Meeting - January 9, 2014
- Winter 2014 – Vemurafenib: Background, Patterns of Resistance, and Strategies to Combat Resistance in Melanoma - January 1, 2014
- Winter 2014 – Substance Use Among Physicians and Medical Students - January 1, 2014
- Winter 2014 – Morphine-induced Myoclonus in a Patient with End-stage Renal Disease - January 1, 2014
- Winter 2014 – Declaration of Helsinki: What Does the Future Hold? - January 1, 2014