Cholinesterase inhibitors for delirium

 

Abstract

Background

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.

Objectives

To assess the efficacy and safety of cholinesterase inhibitors in the treatment of delirium.

Search methods

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.

Selection criteria

Unconfounded, blinded randomised controlled trials, published or unpublished in which treatment with cholinesterase inhibitors was administered and compared with alternative interventions in patients with delirium are included.

Data collection and analysis

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.

Main results

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.

Authors' conclusions

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.

 

Plain language summary

No convincing evidence from one trial of the efficacy of cholinesterase inhibitors for delirium

Delirium is a confusional state that is associated with physical illness. Its characteristic features are rapid onset, altered consciousness, reduced attention and global cognitive impairment. Other symptoms are hallucinations (particularly visual hallucinations), disturbed sleep pattern and agitation. Delirium is commonly found in hospital patients and is associated with longer admissions, poor functioning level, persistent cognitive impairment and need for institutional care. Delirium is therefore an important syndrome to recognise and treat. The one included trial, of donepezil compared with placebo in 15 patients, showed no statistically significant difference in length of delirium. No other outcomes were measured.

 

摘要

背景

失智症病患之按摩和觸拍治療

按摩和觸拍已被建議為一種非藥物治療的替代或補充治療，藉以減少或處理失智症患者的衍生問題，如焦慮，激動行為和憂鬱症。也有人認為按摩和觸拍可減緩認知下降的速度

目標

評估按摩和觸拍療法對失智症患者相關的症狀，如焦慮，激動行為和憂鬱的影響，辨認可能之副作用，並對未來的試驗提供建議

搜尋策略

我們在2005年7月12日，從Specialized Register of the Cochrane Dementia and Cognitive Improvement Group資料庫中搜尋了包含按摩、足部反射、觸拍和指壓按摩等名稱。該系統紀錄所有主要健康照護的資料和正在進行的試驗數據，並定期更新。此外我們也檢索一般和特定資料庫，並聯繫病患和治療師所在機構

選擇標準

隨機對照試驗(RCTs)給予不同類型的失智症的人按摩或觸拍，與採其他治療或未接受治療者比較，效果參數包括行為異常測量，照顧者的負擔，情緒困擾或認知能力。此外，我們採納了一套基本的方法學品質標準，作為選擇的工具

資料收集與分析

我們在初步搜尋時獲得34篇參考文獻。其中7篇確定或可能為隨機對照試驗，但只有2篇符合我們所要求的基本方法學標準

主要結論

從有限的可靠的證據中，結果支持按摩和觸拍對失智症相關的症候有所幫助。不過這方面的證據只針對兩個特定的應用：為即時或短期減少激動行為的手部按摩，及觸拍加上口頭的鼓勵，使病患能達到正常的營養攝取量。目前的證據無法就其療效或可能副作用達成廣泛的結論，而結果也無發現嚴重的副作用

作者結論

按摩和觸拍可作為處理行為、情緒等失智症相關狀況的替代或補充療法。不過還需要進行更多的研究才能為這些治療的好處提供明確的證據

翻譯人

本摘要由高雄長庚醫院顏如君翻譯

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌

總結

沒有足夠實證可為按摩和觸摸對失智症或其衍生的問題得出結論。按摩和觸摸已被建議為藥物治療以外的替代或補充的治療方法，以降低失智症相關的問題如焦慮、激動行為、憂鬱。甚至減緩認知的下降速度。本評論就失智症按摩的現有研究提供概述。我們搜尋到18篇有關按摩療效的研究，但只有兩篇小規模的研究符合嚴謹的方法，來提供其療效的證據。現有少量證據贊成按摩和觸摸的治療，但因證據數量有限以致無法達成結論。此外高品質的隨機對照試驗是必需的