piperidines and Delirium

Sedation practices in the critical care unit have been trending toward lighter sedation since the start of the new millennium, but patients continue to experience inadequate pain management and excessive sedation. This paper includes a brief examination of the problem of pain management in the ICU; trends in sedation practices, including light sedation and the daily interruption of sedation; and a literature review of analgosedation. While the analgosedation literature is relatively sparse, it offers a promising, patient-centered method for managing the triad of pain, agitation, and delirium, while reducing common complications associated with long-term ventilation. This paper concludes with a recommended method for analgosedation, the nursing implications, and a discussion of limitations and recommendations.

Topics: Analgesics; Communication; Delirium; Humans; Hypnotics and Sedatives; Intensive Care Units; Morphine; Pain Management; Patient Outcome Assessment; Piperidines; Psychomotor Agitation; Remifentanil; Respiration, Artificial

The first part of the present review describes the current status of elderly people with behavioral and psychological symptoms of dementia (BPSD) in the community and basic viewpoints for differentiating between different forms of dementia. Specifically, it focuses on four points among the data and research related to determining the current status of elderly people with BPSD. We also propose basic concepts for differentiating between the core symptoms of dementia and BPSD, BPSD and delirium, and agitation and delirium. In the second part of the present review, various aspects of the symptom 'agitation' are discussed based on the experience of our home visit medical service for people with dementia by describing two cases. In cases such as Case 1, where the subject was given high doses of antipsychotics, we believe the problem was that the physicians immediately abstracted all of the abnormal behavior in the subject's life as 'agitation', and provided treatment to the subject accordingly. In Case 2, where the subject had dementia with Lewy bodies (DLB), we propose that it is crucial to differentiate clearly between agitation and delirium. Both of these cases show the risks of focusing treatment simply on agitation. When BPSD occurs in a person with dementia, the burden on caregivers increases. At such times, physicians tend to side with the family rather than with the patient. However, medical care is intended to be for the afflicted person, and physicians should base their plans for medical intervention on this principle.

Topics: Aged; Aged, 80 and over; Antipsychotic Agents; Caregivers; Delirium; Dementia; Diagnosis, Differential; Donepezil; Home Care Services; House Calls; Humans; Indans; Lewy Body Disease; Male; Nootropic Agents; Piperidines; Psychomotor Agitation; Tokyo

Delirium is now the preferred term to describe acute confusional states. It is experienced by 10 to 30% of all hospital inpatients. Delirium is potentially reversible and is related to several adverse outcomes, including increased hospital length of stay, poor functional status, persistent cognitive impairment, need for institutional care and probably mortality. Disruption of the cholinergic system has been proposed as a key mechanism of delirium. Cholinesterase inhibitors enhance the cholinergic system and there have been reports that they might be beneficial in treating delirium.. To assess the efficacy and safety of cholinesterase inhibitors in the treatment of delirium.. The Cochrane Dementia and Cognitive Improvement Group's Register of Clinical Trials (which includes records from MEDLINE, EMBASE, PsycINFO, CINAHL, CENTRAL, LILACS and other databases) was searched for relevant randomised controlled trials using the terms: donepezil or aricept, galantamine or reminyl, rivastigmine OR exelon and tacrine OR cognex on 19 April 2005. As this Specialised Register only contains trials relating to dementia and cognitive impairment, in addition all years of MEDLINE, EMBASE, PsycINFO and CINAHL were searched for trials of cholinesterase inhibitors for delirium in non-demented people.. Unconfounded, blinded randomised controlled trials, published or unpublished in which treatment with cholinesterase inhibitors was administered and compared with alternative interventions in patients with delirium are included.. Two reviewers (RO, SK) independently assessed the quality of the studies according to parameters such as randomisation, blinding and how dropouts were managed. Each cholinesterase inhibitor was to be examined separately and together as a group. The primary outcome measures of interest are length of delirium, severity of delirium and presence and severity of behavioural symptoms (e.g. agitation and hallucinations). Other outcomes of interest include: cognition, need for institutionalisation, length of hospital admission and adverse effects.. There was one included trial of donepezil compared with placebo in 15 patients. No significant difference between the treatment and placebo groups was found in the duration of delirium. The mean duration of postoperative delirium for the donepezil group was 1.0 day (Standard Error 0.0) while for the placebo group it was 1.3 days (Standard Error 0.19). No other outcomes were measured for the patients who developed delirium.. There is currently no evidence from controlled trials that donepezil is effective in the treatment of delirium. Further trials using cholinesterase inhibitors for the treatment of delirium are needed.

Topics: Cholinesterase Inhibitors; Delirium; Donepezil; Humans; Indans; Piperidines

Delirium is very common in the elderly. It complicates both psychiatric and somatic disorders and is associated with reduced survival, poor functional results, increased duration of hospital stay, and institutionalization. Diagnosis remains difficult in spite of the improvement of the diagnostic criteria, due to the polymorphism of the clinical signs and fluctuation of vigilance and cognition. Age over 70 and previous cognitive impairment are the main risk factors. Precipitating factors are medical and surgical pathologies, intoxications, especially by therapeutic drugs. Delirium can reveal or complicate a previous dementia. Prevention of delirium and care of the delirious patient require the participation of both the medical and nursing staff.

Topics: Age Factors; Aged; Aged, 80 and over; Alzheimer Disease; Antipsychotic Agents; Confusion; Delirium; Diagnosis, Differential; Donepezil; Humans; Indans; Patient Care Team; Piperidines; Risk Factors

Delirium is a common mental disorder with serious adverse outcomes in hospitalised patients. It is associated with increases in mortality, physical morbidity, length of hospital stay, institutionalisation and costs to healthcare providers. A range of risk factors has been implicated in its aetiology, including aspects of the routine care and environment in hospitals. Prevention of delirium is clearly desirable from patients' and carers' perspectives, and to reduce hospital costs. Yet it is currently unclear whether interventions for prevention of delirium are effective, whether they can be successfully delivered in all environments, and whether different interventions are necessary for different groups of patients.. Our primary objective was to determine the effectiveness of interventions designed to prevent delirium in hospitalised patients. We also aimed to highlight the quality and quantity of research evidence to prevent delirium in these settings.. We searched the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 28th September, 2005. As the searches in MEDLINE, EMBASE, CINAHL and PsycINFO for the Specialized Register would not necessarily have picked up all delirium prevention trials, these databases were searched again on 28th October, 2005. We also examined reference lists of retrieved articles, reviews and books. Experts in this field were contacted and the Internet searched for further references and to locate unpublished trials.. Randomised controlled trials evaluating any interventions to prevent delirium in hospitalised patients.. Data collection and quality assessment were performed by three reviewers independently and agreement reached by consensus.. Six studies with a total of 833 participants were identified for inclusion. All were conducted in surgical settings, five in orthopaedic surgery and one in patients undergoing resection for gastric or colon cancer. Only one study of 126 hip fracture patients comparing proactive geriatric consultation with usual care was sufficiently powered to detect a difference in the primary outcome, incident delirium. Total cumulative delirium incidence during admission was reduced in the intervention group (OR 0.48 [95% CI 0.23, 0.98]; RR 0.64 [95% CI 0.37, 0.98]), suggesting a 'number needed to treat' of 5.6 patients to prevent one case. The intervention was particularly effective in preventing severe delirium. In logistic regression analyses adjusting for pre fracture dementia and Activities of Daily Living impairment, there was no reduction in effect size, OR 0.6, but this no longer remained significant [95% CI 0.3,1.3]. There was no effect on the duration of delirium episodes, length of hospital stay, and cognitive status or institutionalisation at discharge. There was also no significant difference in cumulative delirium incidence between treatment and control groups in a sub-group of 50 patients with dementia (RR 0.9 [95% CI 0.59, 1.36]). In another trial of low dose haloperidol prophylaxis, there was no difference in delirium incidence but the severity and duration of a delirium episode, and length of hospital stay were all reduced. We identified no completed studies in hospitalised medical, care of the elderly, general surgery, cancer or intensive care patients. In outcomes, no studies examined for death, use of psychotropic medication, activities of daily living, psychological morbidity, quality of life, carers or staff psychological morbidity, cost of intervention and cost to health care services. Outcomes were only reported up to discharge, with no studies reporting medium or longer-term effects.. Research evidence on effectiveness of interventions to prevent delirium is sparse. Based on a single study, a programme of proactive geriatric consultation may reduce delirium incidence and severity in patients undergoing surgery for hip fracture. Prophylactic low dose haloperidol may reduce severity and duration of delirium episodes and shorten length of hospital admission in hip surgery. Further studies of delirium prevention are needed.

Topics: Anesthesia, Epidural; Anesthetics, Inhalation; Cytidine Diphosphate Choline; Delirium; Donepezil; Halothane; Hospitalization; Humans; Indans; Nootropic Agents; Piperidines

To investigate the influence of the midazolam sedation based on remifentanil analgesia on the occurrence of delirium in critically ill patients in intensive care unit (ICU).. A single-center prospective randomized controlled trial was conducted. 140 consecutive critically ill patients admitted to ICU of Peking University People's Hospital, undergoing mechanical ventilation longer than 24 hours, with the need of sedation, from February 2014 to January 2015 were enrolled. They were randomly divided into two groups by computer generated random numbers table, each n = 70. The patients in observation group received midazolam 1 μg x kg(-1) x min(-1) for sedation, and 1 mg/mL remifentanil for analgesia with 0.05 mg/kg intravenous bolus, then continuous infusion of 0.02-0.10 mg x kg(-1) x h(-1). The patients in control group received midazolam for sedation only. The data were recorded as follows: the main indices for observation included the occurrence of delirium and its duration; the second item for observation was consumption of drug for sedation, followed by the mean arterial pressure (MAP) before and after sedation, the time of wake-up, duration of mechanical ventilation, the length of ICU stay, and 28-day fatality rate. The 28-day survival was analyzed by Kaplan-Meier survival curve.. The dosage of remifentanil used in observation group was (98.6 ± 24.9) mg/d, the dosage of midazolam was significantly lower than that of the control group (mg/d: 160.6 ± 33.3 vs. 178.9 ± 43.4, t = 2.829, P = 0.005), the incidence of delirium was obviously lower than that of the control group [22.9% (16/70) vs. 57.1% (40/70), χ2 = 15.700, P < 0.001], and the time of delirium was slightly shorter than that of the control group (hours: 162.9 ± 78.0 vs. 194.8 ± 117.3, t = 0.947, P = 0.348). Among the patients with delirium, the dosage of dexmedetomidine used in observation group was significantly less than that of the control group (mg/d: 0.54 ± 0.11 vs. 0.64 ± 0.14, t = 2.112, P = 0.041). The MAP before sedation was similar as the MAP after sedation in both groups, and there was no significant difference between observation group and control group [mmHg (1 mmHg = 0.133 kPa), before treatment: 84.7 ± 16.2 vs. 89.5 ± 37.7, after treatment: 82.3 ± 10.7 vs. 80.8 ± 13.9, both P > 0.05]. There was no significant difference in the time of waking-up between observation group and control group (hours: 2.3 ± 0.9 vs. 2.4 ± 0.8, t = 0.487, P = 0.627). The duration of mechanical ventilation (hours: 143.4? 138.3 vs. 163.9? 158.9, t = 0.812, P = 0.418), the length of ICU stay (days: 8.8 ± 7.7 vs. 10.0 ± 7.8, t = 0.917, P = 0.361) and 28-day fatality rate [11.4% (8/70) vs. 20.0% (14/70), χ2 = 1.941, P = 0.245] in observation group were slightly lower than those of the control group without significant difference. Kaplan-Meier survival curve showed that the cumulative 28-day survival rate in observation group was slightly higher than that of control group (χ2 = 1.647, P = 0.199) CONCLUSION: Analgesia based on sedation may reduce the occurrence of delirium and its severity, furthermore, even if delirium occurs, it may be less severe.

Topics: Analgesia; Arterial Pressure; Critical Illness; Delirium; Dexmedetomidine; Humans; Hypnotics and Sedatives; Intensive Care Units; Kaplan-Meier Estimate; Midazolam; Pain; Piperidines; Prospective Studies; Remifentanil; Respiration, Artificial

Emergence delirium (ED) refers to a variety of behavioral disturbances commonly seen in children following emergence from anesthesia. Vapor-based anesthesia with sevoflurane, the most common pediatric anesthetic technique, is associated with the highest incidence of ED. Propofol has been shown to reduce ED, but these studies have been methodologically limited.. To conduct a randomized-controlled trial comparing the incidence of ED in children following sevoflurane (SEVO) anesthesia and propofol-remifentanil total intravenous anesthesia (TIVA).. One hundred and twelve children, ASA I-II, aged ≥ 2 and ≤ 6 years, undergoing strabismus repair, were assigned to receive TIVA (intravenous induction and maintenance of anesthesia with propofol and remifentanil) or SEVO (inhalational induction and maintenance of anesthesia with sevoflurane). Parent-child induction behavior was scored using the Perioperative Adult Child Behavior Interaction Scale (PACBIS). Postoperatively, ED was assessed by a masked investigator using the Pediatric Anesthesia Emergence Delirium (PAED) Scale and pain using the Face, Legs, Activity, Cry, Consolability (FLACC) Scale every 5 min.. Data are reported for 94 subjects. Incidence of ED was higher with SEVO (38.3% vs 14.9%, P = 0.018). There was no difference in the median PACBIS score. A higher FLACC score was seen with SEVO (median 3 vs 1, P = 0.033). Subjects experiencing ED had higher FLACC scores vs those unaffected by ED (median 7 vs 1, P < 0.0001).. There was a lower incidence of ED after TIVA. Both intravenous and inhalational inductions were similarly well-tolerated. The use of TIVA was associated with reduced postoperative pain as measured using FLACC scores.

Topics: Anesthesia Recovery Period; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Behavior; Child, Preschool; Delirium; Female; Humans; Interpersonal Relations; Intraoperative Care; Male; Methyl Ethers; Nurses; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Recovery Room; Remifentanil; Sevoflurane; Treatment Outcome

Magnetic resonance imaging (MRI) of children is generally performed under sedation or with general anaesthesia (GA), but the ideal regimen has not been found. The aim of this study was to see if propofol-remifentanil would be a suitable alternative for the maintenance of anaesthesia in this category of patients.. Children aged 1-10 years, American Society of Anesthesiologists physical status 1-2 were included. After induction with thiopental or sevoflurane, the children were randomised to maintenance of anaesthesia with an infusion of propofol and remifentanil (group PR) (56 μg/kg/min of propofol and 0.06 μg/kg/min of remifentanil) or with sevoflurane 1.3 MAC (group S). A binasal catheter was placed in group PR and a laryngeal mask airway in group S. The children breathed spontaneously. The Paediatric Anaesthesia Emergence Delirium (PAED) score (primary end point), the number of movements during MRI, and the length of stay in the recovery room (secondary endpoints) were recorded.. Sixty children were included in each group. A lower level of emergence delirium (measured as a lower PAED score) was found in group PR compared with group S, and the children in group PR were discharged earlier from the recovery room than the children in group S. However, 15 children in group PR vs. 0 in group S moved during the scan (P < 0.001).. The PR infusion ensured a satisfactory stay in the recovery room, but additional boluses were necessary during the MRI. Sevoflurane was reliable during the MRI, but emergence delirium was a concern.

Topics: Anesthesia Recovery Period; Anesthetics, Inhalation; Child; Child, Preschool; Delirium; Double-Blind Method; Endpoint Determination; Female; Humans; Hypnotics and Sedatives; Infant; Magnetic Resonance Imaging; Male; Methyl Ethers; Monitoring, Physiologic; Movement; Patient Satisfaction; Piperidines; Propofol; Remifentanil; Sample Size; Sevoflurane; Treatment Outcome

Sevoflurane is widely used in paediatric anaesthesia but frequently causes emergence agitation (EA). This study evaluated whether limiting the sevoflurane concentration by combining remifentanil with sevoflurane reduced the incidence of EA.. Eighty-four preschool children scheduled for adenotonsillectomy were randomly assigned to either the remifentanil or sevoflurane group. In the remifentanil group, anaesthesia was induced with thiopental, rocuronium, and 1% sevoflurane. It was maintained with 1% sevoflurane, 60% nitrous oxide in oxygen, and a continuous infusion of remifentanil. For the sevoflurane group, anaesthesia was induced with thiopental, rocuronium, and 8% sevoflurane, and was maintained with 2-3% sevoflurane. Both groups received ketorolac 1 mg/kg and dexamethasone 0.15 mg/kg. EA was measured using the paediatric anaesthesia emergence delirium (PAED) scale and a four-point EA scale in the post-anaesthesia care unit.. The scores on the PAED scales were significantly lower in the remifentanil group than in the sevoflurane group [median (interquartile range); 6 (4.25-10.25) vs. 11 (7.75-14.0), P = 0.007], and the proportion of patients with PAED scores ≥ 10 was significantly lower in the remifentanil group than in the sevoflurane group [15 (35.7%) vs. 27 (64.2%), P = 0.009]. The incidence of EA evaluated using the four-point scale was also lower in the remifentanil group [11 (26.1%) vs. 21 (50%), respectively, P = 0.025].. The incidence of EA was lower in children undergoing adenotonsillectomy who received a lower concentration of sevoflurane combined with remifentanil than in those given a higher concentration of sevoflurane without remifentanil.

Topics: Adenoidectomy; Anesthesia Recovery Period; Anesthetics, Inhalation; Anesthetics, Intravenous; Child, Preschool; Delirium; Double-Blind Method; Female; Humans; Male; Methyl Ethers; Piperidines; Postoperative Complications; Psychomotor Agitation; Remifentanil; Sevoflurane; Tonsillectomy

To determine whether donepezil hydrochloride can reduce the prevalence and severity of delirium in older adults undergoing hip fracture repair.. Pilot double-masked randomized placebo-controlled trial.. Large academic medical center.. Sixteen individuals aged 70 and older with hip fracture.. Donepezil 5 mg or placebo was randomly allocated and initiated within 24 hours of surgery, preoperatively or postoperatively. Daily treatment was continued for 30 days or until side effects or the clinical situation required termination.. All outcomes were ascertained masked to treatment status. Information on drug tolerability and safety was obtained from the participant, nurse, and medical record. Delirium presence and severity were measured during daily hospital interviews and at 2, 4, and 6 weeks after surgery after a standardized assessment using the Confusion Assessment Method (CAM) and the Memorial Delirium Assessment Scale (MDAS).. Participants in the donepezil and placebo arms had similar baseline characteristics. Participants in the donepezil arm experienced significantly more side effects. In longitudinal models, there were no significant differences between the donepezil and placebo arms with regard to delirium presence over time (odds ratio = 0.9, 95% confidence interval (CI) = 0.4-2.3) or delirium severity over time (effect size = -0.2 on 30-point MDAS scale, 95%CI = -1.5-1.2).. Participants randomized to donepezil had no significant improvement in delirium presence or severity but experienced more side effects. Overall, sufficient evidence was not found from this pilot study to warrant a definitive Phase III trial.

Topics: Aged; Aged, 80 and over; Cholinesterase Inhibitors; Delirium; Donepezil; Double-Blind Method; Female; Hip Fractures; Humans; Indans; Male; Pilot Projects; Piperidines; Postoperative Complications; Prospective Studies

The aim of this study was to determine whether the concurrent use of either of a subhypnotic dose of midazolam, propofol or ketamine with fentanyl just before discontinuing the sevoflurane anesthesia would effectively sedate the children as they recovered and significantly decrease the incidence and severity of emergence agitation and would not delay patient awakening and discharge.. Postoperative emergence agitation may occur in children after general anesthesia with volatile anesthetics. Children who undergo cataract surgery after sevoflurane induction and sevoflurane-remifentanil maintenance may experience this type of agitation.. In 120 un-premedicated children aged 1-7 years, mask induction with sevoflurane was performed and they were then randomly assigned to one of the three antiagitation postoperative groups (n = 40). We studied the postoperative antiagitation effects of subhypnotic doses of midazolam combined with fentanyl, propofol with fentanyl or ketamine with fentanyl administered just before discontinuing the sevoflurane anesthesia. A score for the level of agitation can be assigned based on the recovery mental state (RMS) scale and the recently published pediatric anesthesia emergence delirium scale (PAED). Postoperative factors assessed included emergence behaviors, the time to eye opening, the time to discharge from the postanesthesia care unit (PACU) to the ward.. There were significantly more agitated children in the ketamine-group when compared to the midazolam-group or to the propofol-group at all time P < 0.05), especially at 10 and 15 min. The PAED scale showed a significant advantage for midazolam-fentanyl [5 (2-15)] and propofol-fentanyl [6 (3-15)] versus ketamine-fentanyl [10 (3-20)] (P < 0.05). The time to discharge from the PACU to the ward was not significantly different among the groups.. Intravenous administration of a subhypnotic dose of midazolam or propofol in addition to a low dose of fentanyl just before discontinuing the sevoflurane anesthesia was both effective on decreasing the incidence and severity of emergence agitation in children undergoing cataract extraction without significant delaying recovery time and discharge. The effect of midazolam was clearer than that seen with propofol.

Topics: Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Dissociative; Anesthetics, Inhalation; Anesthetics, Intravenous; Cataract Extraction; Child; Child, Preschool; Delirium; Double-Blind Method; Female; Fentanyl; Humans; Hypnotics and Sedatives; Infant; Ketamine; Male; Methyl Ethers; Midazolam; Pain Measurement; Piperidines; Postoperative Complications; Propofol; Psychomotor Agitation; Remifentanil; Sevoflurane

This was a pilot, phase 2a study to assess methodological feasibility and the safety and efficacy of donepezil in preventing postoperative delirium after elective total hip replacement surgery in older people without pre-existing dementia. The hypothesis was that donepezil would reduce the incidence of postoperative delirium.. A double blind, placebo controlled, parallel group randomized trial was undertaken. Patients were block randomized pre-operatively to receive placebo or donepezil 5 mg immediately following surgery and every 24 h thereafter for a further three days. The main outcome was the incidence of delirium (using the Delirium Symptom Interview). The secondary outcome was length of hospital stay.. Thirty-three patients (mean age 67 years; 17 males, 16 females) completed the study (19 donepezil, 14 placebo). Donepezil was well tolerated with no serious adverse events. Postoperative delirium occurred in 21.2% of subjects. Donepezil did not significantly reduce the incidence of delirium. The unadjusted risk ratio (donepezil vs placebo) for delirium was 0.29 (95% CI = 0.06,1.30) (chi(2) ([1]) = 3.06; p = 0.08). Mean length of hospital stay was 9.9 days for the donepezil group vs 12.1 days in the placebo group; difference in means = -2.2 days (95% CI = -0.39,4.78) (t([31]) = 1.73: p = 0.09).. The experimental paradigm was feasible and acceptable. Donepezil did not significantly reduce the incidence of delirium or length of hospital stay, however for both outcomes there was a consistent trend suggesting possible benefit. The sample size required for a definitive trial (99% power, alpha 0.05) would be 95 subjects per arm.

Topics: Aged; Aged, 80 and over; Arthroplasty, Replacement, Hip; Delirium; Donepezil; Double-Blind Method; Elective Surgical Procedures; England; Female; Hospitals, Teaching; Humans; Incidence; Indans; Length of Stay; Male; Mental Status Schedule; Middle Aged; Nootropic Agents; Odds Ratio; Piperidines; Postoperative Complications; Treatment Outcome

Remifentanil hydrochloride is an ultra-short acting m-opioid receptor agonist. This study compared the use of remifentanil with that of fentanyl during elective supratentorial craniotomy in a target controlled infusion (TCI)-propofol anesthesia regimen and evaluated the quality of recovery from anesthesia.. After written informed consent for this prospective study, 40 adult patients were randomly divided into 2 groups: in group F analgesia was provided with fentanyl 2-3 mg kg(-1) h(-1) and in group R with remifentanil 0.25 mg kg(-1) h(-1). Anesthesia was induced with thiopental and pancuronium bromide, and maintained with propofol-TCI, pancuronium, air and oxygen and fentanyl (group F) or remifentanil (group R), respectively. After tracheal intubation, infusion rate of remifentanil was reduced and then adjusted to maintain stable hemodynamics. Hemodynamics and recovery time were monitored for 60 min after surgery. Analgesic requirements, propofol intraoperative consumption, nausea and vomiting in postoperative period were monitored. Recovery was evaluated according to a modified Aldrete score.. Baseline hemodynamics were similar in both groups. Mean arterial pressure differed between the 2 groups (P<0.05) with the greatest decrease in group R during dura opening (P<0.001). Postoperative mean arterial pressure was higher in group R. Patients in group R exhibited a faster recovery. The incidence of nausea and vomiting was similar in the 2 groups. Noteworthy, there was a reduction in the amount of propofol used in group R.. Remifentanil appears to be a reasonable alternative to fentanyl during elective surgery of supratentorial lesions.

Topics: Adult; Aged; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Intravenous; Craniotomy; Delirium; Elective Surgical Procedures; Female; Fentanyl; Hemodynamics; Humans; Male; Middle Aged; Pancuronium; Piperidines; Propofol; Prospective Studies; Receptors, Opioid, mu; Remifentanil; Supratentorial Neoplasms; Thiopental

Delirium is a frequent complication of major surgery in older persons. The authors evaluated the possible benefit of donepezil versus placebo in the prevention and treatment of postoperative delirium in an older population without dementia undergoing elective total joint-replacement surgery.. A sample of 80 patients participated in this randomized, double-blind, placebo-controlled trial of donepezil. Each participant was evaluated before surgery and then received donepezil or placebo for 14 days before surgery and 14 days afterward. Postoperative delirium was assessed with the Delirium Symptom Interview, Confusion Assessment Method, daily medical record, nurse-observation reviews, and DSM-IV diagnostic criteria for delirium. Subsyndromal delirium was also assessed for each participant.. Delirium, diagnosed by DSM-IV criteria, was found on at least 1 postoperative day in 18.8% of subjects, but there were no significant differences between the donepezil and placebo groups. When delirium was present, it lasted only 1 day, and there was no difference between the groups. Subsyndromal delirium was found on at least 1 postoperative day for 68.8% of subjects, and, when this occurred, lasted 2 days or less, on average. There was no difference between the groups in the occurrence or duration of subsyndromal delirium. There was no difference between the groups in disposition to home or to another facility.. This pilot study was unable to demonstrate a benefit for donepezil in preventing or treating delirium in a relatively young and cognitively-intact group of elderly patients undergoing elective orthopedic surgery. Furthermore, postoperative delirium was not a major problem in this population.

Topics: Aged; Aged, 80 and over; Cholinesterase Inhibitors; Delirium; Donepezil; Double-Blind Method; Female; Humans; Indans; Male; Middle Aged; Pilot Projects; Piperidines; Postoperative Complications

No standardized instrument exists for the systematic analysis of emergence behaviour in children after anaesthesia. Our purpose was to evaluate children's behaviour prior to anaesthetic induction and immediately upon emergence to develop an assessment tool using psychiatric terminology and techniques.. This prospective study evaluated 25 children from 2 to 9 years of age for preanaesthetic psychosocial factors that might affect behaviour. Children's behaviour was observed from admission to the surgical unit through the induction of anaesthesia. All children received a standardized premedication and induction of anaesthesia. The maintenance anaesthetic was randomized to intravenous remifentanil or inhaled isoflurane. All children underwent repair of strabismus. We assessed the behaviour of children for 30 min upon emergence from anaesthesia for symptoms of pain, distress and delirium using an assessment tool we developed guided by the principles of psychiatry as described in Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).. Using our assessment tool, 44% of children demonstrated altered behaviour on emergence; 20% demonstrated complex symptoms with characteristics of delirium. Children anaesthetized with isoflurane had significantly higher postanaesthesia behaviour assessment scores than those anaesthetized with remifentanil (P = 0.04). Age was a significant variable; children <62 months were more prone to altered behaviour than those >62 months (P = 0.02). Scores did not correlate with preanaesthetic risk factors including preexisting psychological or social variables or observed preanaesthetic distress. There was no delay in hospital discharge in children assessed as having altered behaviour.. This exploratory study suggests that postanaesthetic behaviour abnormalities with characteristics of distress or delirium can be categorized using known DSM-IV terminology; in our cohort this behaviour was dependent on age and anaesthetic technique.

Topics: Age Factors; Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Child; Child Behavior; Child, Preschool; Delirium; Female; Humans; Isoflurane; Pain, Postoperative; Piperidines; Prospective Studies; Psychiatric Status Rating Scales; Psychomotor Agitation; Random Allocation; Remifentanil

Torsade de pointes (TdP) occurred in a long QT syndrome type 3 (LQT3) patient after switching perospirone to blonanserin. We studied how their electropharmacological effects had induced TdP in the LQT3 patient. Perospirone hydrochloride (n = 4) or blonanserin (n = 4) of 0.01, 0.1, and 1 mg/kg, i.v. was cumulatively administered to the halothane-anesthetized dogs over 10 min. The low dose of perospirone decreased total peripheral vascular resistance, but increased heart rate and cardiac output, facilitated atrioventricular conduction, and prolonged J-T

Topics: Action Potentials; Anesthetics, Inhalation; Animals; Calcium Channel Agonists; Cardiac Conduction System Disease; Delirium; Dogs; Dopamine Antagonists; Dose-Response Relationship, Drug; Electrocardiography; Female; Halothane; Heart Conduction System; Humans; Isoindoles; Long QT Syndrome; Middle Aged; Models, Animal; Piperazines; Piperidines; Potassium Channel Blockers; Serotonin Antagonists; Sleep Initiation and Maintenance Disorders; Thiazoles; Torsades de Pointes

Topics: Acetaminophen; Aged; Aged, 80 and over; Automobile Driving; Cognition Disorders; Cognitive Dysfunction; Colonic Neoplasms; Delirium; Dementia; Donepezil; Early Detection of Cancer; Estrogen Replacement Therapy; Female; Geriatrics; Humans; Indans; Male; Neuropsychological Tests; Nootropic Agents; Oxycodone; Piperidines; Urinary Incontinence; Watchful Waiting

Topics: Anticholinergic Syndrome; Antiparkinson Agents; Antipsychotic Agents; Biperiden; Burns; Cholinesterase Inhibitors; Delirium; Diagnosis, Differential; Donepezil; Drug Administration Routes; Drug Synergism; Humans; Indans; Male; Middle Aged; Muscle Rigidity; Physostigmine; Piperidines; Risperidone; Treatment Outcome

Delirium is defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) as a potentially reversible disturbance of consciousness and a change of cognition caused by a medical condition, drug intoxication, or medication side effect. Delirium affects up to 80 % of intensive care unit (ICU) patients and is associated with increased morbidity and mortality. One risk factor for development of delirium in ventilated intensive care unit patients is sedation. The German S3 guidelines on "Analgesie, Sedierung und Delirmanagement in der Intensivmedizin" (analgesia, sedation and delirium management in intensive care medicine) of the DGAI (German Society for Anesthesiology and Intensive Care Medicine) and the DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine) recommend midazolam and propofol for sedation, although both drugs are associated with a high incidence of delirium.. Within the framework of this study the question arose whether the barbiturate methohexital could be associated with a lower incidence of delirium in comparison to midazolam or propofol in analgosedated and ventilated ICU patients.. This was a prospective nonrandomized observational cohort study in a mixed medical surgical intensive care unit. Patients ventilated within 72 h after admittance were consecutively allocated to either propofol/remifentanil versus methohexital/remifentanil (expected ventilation duration ≤ 7 days) or midazolam/fentanyl versus methohexital/fentanyl (expected ventilation duration > 7 days) by the attending senior consultant anesthetist at the time of admission and/or intubation. Primary endpoint was delirium at any time during the ICU stay. Delirium was checked every 8 h by ICU nurses using the intensive care delirium screening checklist (ICDSC), with delirium defined as ICDSC ≥ 4 points. Before evaluation of the ICDSC the Richmond agitation sedation scale (RASS) score and the visual analogue scale for pain (VAS target ≤ 4) were measured. To assure reliable evaluation of the ICDSC, the RASS score of the patient at the time of evaluation had to be ≥ - 2. Assuming an incidence of delirium in the midazolam group of 70 % and in the methohexital group of 35 %, 16 patients were needed each in the midazolam/fentanyl and the methohexital/fentanyl cohorts (p = 0.05, β = 0.1). Assuming an incidence of delirium in the propofol group of 50 % and in the methohexital group again of 35 %, 94 patients were needed in the propofol/remifentanil and methohexital/remifentanil groups, respectively (p = 0.05, β = 0.1).. A total of 222 patients were evaluated, 34 in the methohexital vs. midazolam group and 188 in the methohexital vs. propofol group. Out of 16 patients sedated with midazolam, 15 developed delirium (94 %) in contrast to only 5 out of 18 patients sedated with methohexital (28 %). Thus compared to midazolam the sedation with methohexital reduced the incidence of delirium by 66 % (p < 0.001) corresponding to a number needed to treat (NNT) of 1.5. Out of 94 patients in the propofol/remifentanil group, 64 developed delirium (68 %) in contrast to only 23 out of 94 in the methohexital/remifentanil group (24 %). Thus compared to propofol the sedation with methohexital reduced the incidence of delirium by 44 % (p < 0.001), corresponding to an NNT of 2.5.. Sedation with methohexital compared to midazolam or propofol reduced the incidence of delirium by more than 50 % in ventilated ICU patients.

Topics: Aged; Analgesics, Opioid; Anesthetics, Intravenous; Checklist; Cohort Studies; Critical Care; Delirium; Drug Therapy, Combination; Female; Humans; Hypnotics and Sedatives; Male; Methohexital; Middle Aged; Piperidines; Propofol; Prospective Studies; Psychomotor Agitation; Remifentanil; Respiration, Artificial

Topics: Aged; Critical Care; Delirium; Emergency Treatment; Female; Humans; Male; Pilot Projects; Piperazines; Piperidines; Treatment Outcome

We describe a 62-year-old female diagnosed with Alzheimer's disease, who had been treated with donepezil for approximately 1 year. When she developed a low-grade fever and digestive complaints, her family physician interpreted these symptoms as side effects of the drug and ordered donepezil to be discontinued. Not only was there no improvement of the somatic symptoms after discontinuation of donepezil, but there was also a worsening of the dementia symptoms, culminating in delirium. When donepezil was re-prescribed, the delirium resolved and the patient's mental state stabilized. The authors urge great caution in discontinuing treatment with acetylcholinesterase inhibitors such as donepezil.

Topics: Alzheimer Disease; Cholinesterase Inhibitors; Delirium; Dementia; Donepezil; Female; Humans; Indans; Middle Aged; Piperidines; Substance Withdrawal Syndrome; Withholding Treatment

Electroconvulsive therapy is safe and effective in the treatment of depression in older individuals. Minor cognitive side effects of electroconvulsive therapy include acute postictal confusion and reversible short-term memory deficits. However, interictal delirium is uncommon in absence of risk factors. Herein, we report the case a depressed male patient without any known risk factors who developed interictal delirium 2 days after his sixth electroconvulsive therapy session. Interictal delirium improved with treatment within 1 week.

Topics: Cholinesterase Inhibitors; Delirium; Depressive Disorder; Donepezil; Electroconvulsive Therapy; Follow-Up Studies; Haloperidol; Humans; Hypnotics and Sedatives; Indans; Lorazepam; Male; Middle Aged; Piperidines; Risk Factors; Time Factors

The purpose of the present study was to provide preliminary data on the usefulness and safety of blonanserin for patients with delirium in the intensive care unit (ICU). The charts of 32 consecutive patients with delirium in the ICU were retrospectively reviewed. These patients were treated with blonanserin. A total of 96.6% had reduction in Memorial Delirium Assessment Scale score. The proportion of patients with side-effects was 24.1%. Blonanserin may be effective and safe in the treatment of delirium in the ICU.

Topics: Adult; Aged; Aged, 80 and over; Antipsychotic Agents; Delirium; Dopamine Antagonists; Female; Humans; Male; Middle Aged; Piperazines; Piperidines; Retrospective Studies; Serotonin Antagonists; Treatment Outcome

Topics: Antitussive Agents; Child, Preschool; Delirium; Drug Overdose; Humans; Male; Piperidines

Topics: Aged; Antipsychotic Agents; Delirium; Humans; Male; Piperazines; Piperidines; Pneumonia; Psychiatric Status Rating Scales; Psychomotor Agitation; Risperidone

Delirium and agitation are commonly encountered after administration of electroconvulsive therapy (ECT). Management is generally fairly straightforward, although some patients may have a severe, prolonged, or refractory course. We recently cared for a 65-year-old man who consistently developed severe and very prolonged post-ECT delirium that did not respond to typical pharmacological agents; the duration of delirium was dramatically shortened by the addition of donepezil. Cholinesterase inhibitors may have a place in mitigating severe and prolonged post-ECT delirium.

Topics: Aged; Cholinesterase Inhibitors; Delirium; Depressive Disorder, Major; Donepezil; Electroconvulsive Therapy; Humans; Indans; Male; Piperidines; Psychomotor Agitation

A severe intractable delirium caused by the basal forebrain vascular lesion and its dramatic recovery after donepezil administration were reported. A 68-year-old man had suffered for a month from delirium of mixed type caused by the right basal forebrain vascular lesion after surgery for craniopharyngioma. Magnetic resonance imaging (MRI) showed hemorrhagic infarcts in the head of the right caudate nucleus and the right basal forebrain of the medial septal nucleus, diagonal band of Broca and nucleus basalis of Meynert. He had been treated with anti-psychotics, anti-depressants and hypnotics, which resulted in little improvement. Donepezil administration dramatically improved his intractable delirium at the 19th post-donepezil administration day, but this was followed by amnestic symptoms. Clinical correlates of delirium with the basal forebrain lesion and efficacy of donepezil support the hypocholinergic theory of delirium.

Topics: Aged; Basal Ganglia Cerebrovascular Disease; Basal Nucleus of Meynert; Craniopharyngioma; Delirium; Donepezil; Humans; Indans; Magnetic Resonance Imaging; Male; Nootropic Agents; Piperidines; Pituitary Neoplasms; Postoperative Complications; Prosencephalon; Sleep Wake Disorders; Vision Disorders

We present a case of delirium due to amitriptyline overdose, which resolved rapidly following initiation of the cholinesterase inhibitor donepezil. The authors discuss the possibility of cholinesterase inhibitors being an effective choice in the management of anticholinergic drug induced delirium.

Topics: Amitriptyline; Cholinergic Antagonists; Delirium; Donepezil; Drug Overdose; Humans; Indans; Male; Middle Aged; Piperidines

Topics: Aged; Alzheimer Disease; Atrophy; Cerebral Cortex; Delirium; Donepezil; Humans; Indans; Male; Nootropic Agents; Piperidines

Topics: Aged; Alzheimer Disease; Delirium; Donepezil; Geriatric Assessment; Humans; Indans; Male; Nootropic Agents; Piperidines; Postoperative Complications; Time Factors

Topics: Aged; Brain; Delirium; Dementia; Donepezil; Humans; Indans; Lewy Bodies; Magnetic Resonance Imaging; Male; Nootropic Agents; Piperidines; Psychiatric Status Rating Scales

Delirium is a common complication of dementia and may produce considerable morbidity. In addition to psychotic symptoms such as hallucinations and delusions, delirium may produce considerable agitation, which may be refractory to conventional medications such as antipsychotics and benzodiazepines. The main approach to delirium is to treat any underlying medical problem that could cause the delirium. However, delirium is not always reversible, and there is no specific treatment for persistent delirium. The authors present a case of delirium complicating a preexisting dementia that resolved rapidly following initiation of the cholinesterase inhibitor donepezil, suggesting that cholinergic dysfunction may have played a role in the etiology of this patient's delirium. Future research needs to be directed at the issue of cholinergic activity in delirium through monitoring of serum anticholinergic activity and its response to procholinergic therapy.

Topics: Aged; Alcohol Withdrawal Delirium; Cholinesterase Inhibitors; Cognition Disorders; Delirium; Dementia; Donepezil; Humans; Indans; Male; Mood Disorders; Piperidines; Treatment Outcome

We report on two cases of self-induced intoxication with the anticholinergic agent biperiden (oral ingestion of at least 200 mgs. in case 1, and of 60 mgs. in combination with 300-400 mgs levomepromazine in case 2). An acute delirious state and other somatic symptoms of a toxic anticholinergic action dominated the clinical picture. Serial measurements of biperiden serum levels revealed values up to 50-fold (case 1) and 15-fold (case 2) of those usually observed under therapeutic doses of biperiden. In both cases, the intoxication was controlled by the application of physostigmine and general therapeutic measures. We discuss the prognosis of biperiden intoxications, and the clinical symptomatology and therapy of drug-induced anticholinergic syndromes.

Topics: Adult; Biperiden; Delirium; Humans; Male; Methotrimeprazine; Piperidines; Schizophrenic Psychology; Suicide, Attempted

Topics: Acridines; Adult; Atropine; Behavior; Blood Pressure; Central Nervous System; Delirium; Glycolates; Heart Rate; Human Experimentation; Humans; Isoflurophate; Male; Memory; Methylphenidate; Neostigmine; Parasympatholytics; Physostigmine; Piperidines; Respiration; Sarin; Scopolamine

Topics: Adult; Child; Child, Preschool; Delirium; Exanthema; Female; Gels; Hallucinations; Histamine H1 Antagonists; Humans; Hypersensitivity; Male; Ointments; Piperidines; Psychoses, Substance-Induced

Topics: Child; Delirium; Diagnosis, Differential; Encephalitis; Female; Gels; Histamine H1 Antagonists; Humans; Piperidines; Psychoses, Substance-Induced