Korean Journal of Psychosomatic Medicine (정신신체의학)

Korean Psychosomatic Society (한국정신신체의학회)
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Clinical Course according to Antipsychotics Prescription Pattern in Delirium

섬망 환자에서 항정신병약물 처방 유형에 따른 임상 경과의 차이

  • Park, Jaesub (Department of Psychiatry and Institute of Behavioral Science in Medicine, Yonsei University College of Medicine) ;
  • Kim, Jae-Jin (Department of Psychiatry and Institute of Behavioral Science in Medicine, Yonsei University College of Medicine) ;
  • Park, Sungjong (Department of Psychiatry and Institute of Behavioral Science in Medicine, Yonsei University College of Medicine) ;
  • Kim, Sungmin (Department of Psychiatry, Gangnam Severance Hospital, Yonsei University Health System) ;
  • Park, Jin Young (Department of Psychiatry and Institute of Behavioral Science in Medicine, Yonsei University College of Medicine)
  • 박재섭 (연세대학교 의과대학 강남세브란스병원 정신건강의학교실) ;
  • 김재진 (연세대학교 의과대학 강남세브란스병원 정신건강의학교실) ;
  • 박성종 (연세대학교 의과대학 강남세브란스병원 정신건강의학교실) ;
  • 김성민 (연세대학교 의과대학 정신과학교실 및 의학행동과학연구소) ;
  • 박진영 (연세대학교 의과대학 강남세브란스병원 정신건강의학교실)
  • Received : 2017.07.04
  • Accepted : 2017.07.30
  • Published : 2017.12.31
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Abstract

Objectives : Although antipsychotics are commonly used to control symptoms of delirium, there is a lack of research on the prescription pattern and its clinical effects. The purpose of this study was to investigate the effect of antipsychotics prescription pattern on clinical course of delirious patients consulted to psychiatry. Methods : During the period from July 2016 to February 2017, 212 patients who were referred for delirium were reviewed for their medical records. The duration of delirium was monitored using CAM-ICU, and duration of admission, mortality, and delirium at discharge were reviewed. Clinical course was compared among three groups according to the antipsychotic drug administration pattern: Continuous use group, optimal use group and PRN use group. Results : The pattern of taking antipsychotic medication longer than duration of delirium did not associated with better clinical course compared with the pattern of adapting to the period of delirium and rather increased the risk of taking antipsychotic medication at discharge. When used for a shorter period than the delirium period, it was associated with poor clinical course. Conclusions : The results of this study suggest that a strategy to administer antipsychotics for a minimum period, according to periods of delirium, is appropriate. Also, efforts are needed to minimize the use of antipsychotic drugs after recovery from delirium.

연구목적 섬망의 증상을 조절하기위해 일반적으로 항정신병약물이 사용되지만, 투약 기간 및 용법과 같은 처방 양상과 환자의 임상 경과 사이의 연관성에 대한 연구는 아직 부족한 상태이다. 이 연구를 통해 섬망을 경험한 환자에서 항정신병약물의 처방 양상에 따라 임상 경과에 차이가 있는지 확인하고자 하였다. 방 법 서울의 일 종합병원에서 섬망으로 자문조정이 의뢰된 입원 환자 중 2016년 7월부터 2017년 2월까지 퇴원한 212명을 대상으로 하였다. 환자의 전자의무기록을 후향적으로 검토하여 입원 기간, 사망, 인구통계학적 자료 및 임상적 요인을 조사하였고, CAM-ICU를 통해 섬망 지속 기간을 측정하였다. 항정신병약물의 처방 유형에 따라 지속투약군, 최적투약군, 필요투약군으로 나누어 임상 경과를 비교하였다. 결 과 항정신병약물을 섬망 회복 후에도 지속적으로 투약 받은 지속투약군은 섬망 증상이 있는 기간에만 투약 받은 최적투약에 비하여 입원 기간 및 섬망 이환기간에 유의한 차이가 없었으며, 퇴원시 불필요한 항정신병약물 처방을 받은 비율이 높았다. 섬망 이환기간에 비해 짧은 기간 항정신병약물을 사용한 필요투약군은 다른 두 군에 비해 섬망 이환기간이 길고 사망률이 높았다. 결 론 이 연구의 결과는 섬망 이환기간에만 항정신병약물을 투여하는 것이 적절함을 시사한다. 또한 섬망이 회복된 후에 불필요하게 항정신병약물이 처방되는 것을 최소화하기위한 정신건강의학과 자문의의 적극적인 개입이 필요하겠다.

Keywords

References

  1. Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet 2014;383:911-922. https://doi.org/10.1016/S0140-6736(13)60688-1
  2. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental disorders(5th ed.; DSM-5). New York: American Psychiatric Association;2013. p.596-602
  3. Peritogiannis V, Stefanou E, Lixouriotis C, Gkogkos C, Rizos DV. Atypical antipsychotics in the treatment of delirium. Psychiatry Clin Neurosci 2009;63:623-631. https://doi.org/10.1111/j.1440-1819.2009.02002.x
  4. Yoon HJ, Park KM, Choi WJ, Choi SH, Park JY, Kim JJ, Seok JH. Efficacy and safety of haloperidol versus atypical antipsychotic medications in the treatment of delirium. BMC Psychiatry 2013;13:240. https://doi.org/10.1186/1471-244X-13-240
  5. Neufeld KJ, Yue J, Robinson TN, Inouye SK, Needham DM. Antipsychotic Medication for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta-Analysis. J Am Geriatr Soc 2016;64:705-714. https://doi.org/10.1111/jgs.14076
  6. Friedman JI, Soleimani L, McGonigle DP, Egol C, Silverstein JH. Pharmacological Treatments of Non-Substance-Withdrawal Delirium: A Systematic Review of Prospective Trials. Am J Psychiatry 2014;171:151-159. https://doi.org/10.1176/appi.ajp.2013.13040458
  7. Lonergan E, Britton AM, Luxenberg J. Antipsychotics for delirium. Cochrane Database Syst Rev. John Wiley & Sons, Ltd;2007. p.1-17.
  8. Al-Qadheeb NS, Skrobik Y, Schumaker G, Pacheco MN, Roberts RJ, Ruthazer RR, Devlin JW. Preventing ICU Subsyndromal Delirium Conversion to Delirium With Low-Dose IV Haloperidol: A Double-Blind, Placebo-Controlled Pilot Study. Crit Care Med 2016;44:583-591. https://doi.org/10.1097/CCM.0000000000001411
  9. Fok MC, Sepehry AA, Frisch L, Sztramko R, Borger van der Burg BLS, Vochteloo AJH, Chan P. Do antipsychotics prevent postoperative delirium? A systematic review and meta-analysis. Int J Geriatr Psychiatry 2015;30:333-344. https://doi.org/10.1002/gps.4240
  10. Kim DH, Huybrechts KF, Patorno E, Marcantonio ER, Park Y, Levin R, Abdurrob A, Bateman BT. Adverse Events Associated with Antipsychotic Use in Hospitalized Older Adults After Cardiac Surgery. J Am Geriatr Soc 2017;65:1229-1237. https://doi.org/10.1111/jgs.14768
  11. Kales HC, Kim HM, Zivin K, Valenstein M, Seyfried LS, Chiang C, Cunningham F, Schneider LS, Blow FC. Risk of Mortality Among Individual Antipsychotics in Patients With Dementia. Am J Psychiatry 2012;169:71-79. https://doi.org/10.1176/appi.ajp.2011.11030347
  12. National Clinical Guideline Centre UK. Delirium: Diagnosis, Prevention and Management. the National Institute for Health and Clinical Excellence;2010. p.299-376.
  13. Hu Hua, Deng Wei, Yang Hui, Liu Yu. Olanzapine and Haloperidol for Senile Delirium: A Randomized Controlled Observation. Chinese Journal of Clinical Rehabilitation 2006;42:188-190.
  14. Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BR, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R, American College of Critical Care M. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41:263-306. https://doi.org/10.1097/CCM.0b013e3182783b72
  15. Baron R, Binder A, Biniek R, Braune S, Buerkle H, Dall P, Demirakca S, Eckardt R, Eggers V, Eichler I, Fietze I, Freys S, Fründ A, Garten L, Gohrbandt B, Harth I, Hartl W, Heppner H-J, Horter J, Huth R, Janssens U, Jungk C, Kaeuper KM, Kessler P, Kleinschmidt S, Kochanek M, Kumpf M, Meiser A, Mueller A, Orth M, Putensen C, Roth B, Schaefer M, Schaefers R, Schellongowski P, Schindler M, Schmitt R, Scholz J, Schroeder S, Schwarzmann G, Spies C, Stingele R, Tonner P, Trieschmann U, Tryba M, Wappler F, Waydhas C, Weiss B, Weisshaar G. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015(DAS-Guideline 2015)-short version. Ger Med Sci 2015;13:4-8.
  16. Meagher DJ, McLoughlin L, Leonard M, Hannon N, Dunne C, O'Regan N. What Do We Really Know About the Treatment of Delirium with Antipsychotics? Ten Key Issues for Delirium Pharmacotherapy. Am J Geriatr Psychiatry 2013;21:1223-1238. https://doi.org/10.1016/j.jagp.2012.09.008
  17. Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R, Speroff T, Gautam S, Bernard GR, Inouye SK. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit(CAMICU). Crit Care Med 2001;29:1370-1379. https://doi.org/10.1097/00003246-200107000-00012
  18. Heo EY, Lee BJ, Hahm BJ, Song EH, Lee HA, Yoo CG, Kim YW, Han SK, Shim YS, Lee SM. Translation and validation of the Korean confusion assessment method for the intensive care unit. BMC Psychiatry 2011;11:94. https://doi.org/10.1186/1471-244X-11-94
  19. Ely EW. The Confusion Assessment Method for the ICU (CAM-ICU) The Complete Training Manual. Nashville: ICU Delirium and Cognitive Impairment Study Group. Vanderbilt University Medical Center;2016. p.16-21.
  20. Page VJ, Ely EW, Gates S, Zhao XB, Alce T, Shintani A, Jackson J, Perkins GD, McAuley DF. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients(Hope-ICU): a randomised, double-blind, placebocontrolled trial. Lancet Respir Med 2013;1:515-523. https://doi.org/10.1016/S2213-2600(13)70166-8
  21. Briskman I, Dubinski R, Barak Y. Treating delirium in a general hospital: a descriptive study of prescribing patterns and outcomes. Int Psychoger 2010;22:328-331. https://doi.org/10.1017/S1041610209990986
  22. Bae JH, Kang WS, Paik JW, Kim JW. Changing trends in the occurrence and management of delirium for 5 years in a university hospital. Korean J Psychosom Med 2012;20:112-119.
  23. Paik SH, Min S, Ahn JS, Park KC, Kim MH. Symptomatic and Clinical Profiles Across Motoric Subtypes in Delirium. Korean J Psychosom Med 2015;23:79-85.
  24. Flurie RW, Gonzales JP, Tata AL, Millstein LS, Gulati M. Hospital delirium treatment: Continuation of antipsychotic therapy from the intensive care unit to discharge. Am J Health Syst Pharm 2015;72:133-139. https://doi.org/10.2146/ajhp140106
  25. Herzig SJ, Rothberg MB, Guess JR, Stevens JP, Marshall J, Gurwitz JH, Marcantonio ER. Antipsychotic use in hospitalized adults: rates, indications, and predictors. J Am Geriatr Soc 2016;64:299-305. https://doi.org/10.1111/jgs.13943
  26. Jasiak KD, Middleton EA, Camamo JM, Erstad BL, Snyder LS, Huckleberry YC. Evaluation of Discontinuation of Atypical Antipsychotics Prescribed for ICU Delirium. J Pharm Pract 2013;26:253-256. https://doi.org/10.1177/0897190012465987
  27. Tolppanen A-M, Koponen M, Tanskanen A, Lavikainen P, Sund R, Tiihonen J, Hartikainen S, Taipale H. Antipsychotic Use and Risk of Hospitalization or Death Due to Pneumonia in Persons With and Those Without Alzheimer Disease. Chest 2016;150:1233-1241. https://doi.org/10.1016/j.chest.2016.06.004
  28. Bozat-Emre S, Doupe M, Kozyrskyj AL, Grymonpre R, Mahmud SM. Atypical antipsychotic drug use and falls among nursing home residents in Winnipeg, Canada. Int J Geriatr Psychiatry 2015;30:842-850. https://doi.org/10.1002/gps.4223
  29. Johnell K, Jonasdottir Bergman G, Fastbom J, Danielsson B, Borg N, Salmi P. Psychotropic drugs and the risk of fall injuries, hospitalisations and mortality among older adults. Int J Geriatr Psychiatry 2017;32:414-420. https://doi.org/10.1002/gps.4483
  30. Vandael E, Vandenberk B, Vandenberghe J, Willems R, Foulon V. Risk factors for QTc-prolongation: systematic review of the evidence. Int J Clin Pharm 2017;39:16-25. https://doi.org/10.1007/s11096-016-0414-2
  31. Kooi AWvd, Peelen LM, Raijmakers RJ, Vroegop RL, Bakker DF, Tekatli H, Boogaard Mvd, Slooter AJC. Use of Physical Restraints in Dutch Intensive Care Units: A Prospective Multicenter Study. Am J Crit Care 2015;24:488-495. https://doi.org/10.4037/ajcc2015348
  32. Chevrolet JC, Jolliet P. Clinical review: Agitation and delirium in the critically ill-significance and management. Crit Care 2007;11:214. https://doi.org/10.1186/cc5787