Dementia, Delirium, and Depression in Older Adults

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Table of Contents

Introduction
PICO Analysis of Research Topic
Analysis of Literature
Conclusion
Literature Matrix
References

Introduction

For geriatric patients, changes in health can lead to serious consequences that often impact individuals’ physical and mental health. Strong effects of chronic illnesses, medication, surgery, infection, and pain are especially prevalent in older people with frailty and lowered resistance to outside factors (Resnick, 2016). As a result, some patients may develop delirium – a condition that is characterized by cognitive impairment, emotional disturbances, behavior changes, and changes in spatial awareness (Holroyd-Leduc & Reddy, 2012). While delirium cases are often temporary, the treatment options for this issue have been researched to shorten the episodes and mitigate the results of mental abilities’ disturbance. This research aims to investigate the treatment options for dementia in older patients and perform a PICO analysis to determine the effectiveness of antipsychotics for the condition.

PICO Analysis of Research Topic

Delirium in the elderly is a serious problem that can have significant and long-lasting effects on their wellbeing. Thus, it is vital to research various therapy approaches, including the possible use of pharmacological options. The PICO framework requires one to define four aspects that will be taken into account during the study’s completion – “patient, intervention, comparison, outcome” (Eriksen & Frandsen, 2018, p. 420). In this case, the researched population is hospitalized patients with delirium, especially older adults. The intervention under analysis is antipsychotics, which are prescribed to lower the severity of delirium episodes and shorten their duration (Oh, Fong, Hshieh, & Inouye, 2017). The comparison is no pharmacological treatment or placebo to exclude the use of other medications, and the outcome is the reduction of delirium severity. Therefore, the final PICO question is, “In hospitalized older adult patients (P), is the use of antipsychotics (I), in comparison to no medication (C), more effective for treating delirium?”

Search Strategy

The search for appropriate data relies on the quality of selected databases and search terms. To gather information, this research utilized PubMed, CINAHL, Cochrane Reviews, and Google Scholar. Search terms’ selection was based on the fact that the studies needed to explore the effect of antipsychotics on older adult patients. At first, the terms included “age,” “elderly,” “delirium,” and “antipsychotics.” The criteria were to include English primary studies and systematic reviews not older than five years. However, due to the lack of results, later searches also added articles about the general adult population since their focus seemed to stay on geriatric patients. As a result, the Boolean search strings were “elderly AND delirium AND antipsychotics” and “adult AND delirium AND (antipsychotics OR pharmacological).”

Analysis of Literature

Five recent articles were selected as the result of the search. In the first study, Cerveira, Pupo, Santos, and Santos (2017) examine the effects of drug-based and non-pharmacological treatments for delirium in the elderly. This is a systematic review with the highest level of evidence, and it is not based on a conceptual framework. The authors collect data from ten articles and find that four studies describing pharmacological interventions supported the effectiveness of such antipsychotic drugs as droperidol, rivastigmine, olanzapine, and haloperidol (Cerveira et al., 2017). The strength of this study is its method – as a systematic review, the research is based on multiple sources. Nonetheless, the authors look only at four articles discussing drug therapy, and most of the selected researches are outdated; their conclusions are less reliable than they could be.

The next study is by Lee, Kim, Ahn, and Kim (2017), who investigate the outcomes of using antipsychotics in the elderly population. This is a cohort study without a theoretical basis that divided its participants into four groups – three using and one not using antipsychotic medication. The results showed no significant distinctions among the groups, leading Lee et al. (2017) to conclude that all patients’ delirium improved with time, regardless of their therapy plan. The level of evidence is V, and the study’s lack of randomization in group creation is a definite weakness since it may lead to biased results. However, the authors’ use of standard tools and clear separation of patients according to their therapy plan provides transparent results, which increases the article’s reliability.

The outcomes of using antipsychotics on adult hospitalized patients are also researched by Mehta et al. (2018). Scholars complete a systematic review (first level of evidence) to compare patients’ outcomes with and without antipsychotic drugs and to see whether there exists a difference between the use of typical and atypical medications. Mehta et al. (2018) examine nine randomized and quasi‐randomized trials and find no evidence that antipsychotics (both typical and atypical) have more positive effects on patients than a plan without these drugs. The authors underline that antipsychotic therapy was no more effective than non-medicine treatments in shortening the duration of delirium episodes, resolving symptoms, or altering mortality (Mehta et al., 2018). The primary strengths of the study lie in its amount of data and its analysis, while the main weakness, as reported by the scholars, is the low quality of available evidence.

The next systematic review (first level of evidence) was performed by Neufeld, Yue, Robinson, Inouye, and Needham (2016), who also considered the use of antipsychotics for treating delirium in hospitalized adults. The researchers identify 19 articles, and the synthesis of evidence shows that antipsychotic therapy, in comparison with placebo or no treatment, does not have a substantial effect on incidence, severity, and duration of delirium episodes (Neufeld et al., 2016). In this study, the authors use a large number of articles, and the latter are appraised by the panel of experts supported by the American Geriatrics Society. However, the lack of available studies about the elderly population has forced scholars to include a wider adult population, which is a possible weak point of the study.

In the final selected study, Nguyen, Malachane, and Minh (2017) investigate the patterns of antipsychotic prescriptions to elderly patients with delirium symptoms. They conduct a retrospective cohort-sectional study (V level of evidence) and do not use a theoretical framework. Nguyen et al. (2017) find that antipsychotics are prescribed to almost four-thirds of the chosen population. The outcomes of the study indicate that these drugs lead to the shortening of the delirium episodes duration. Nonetheless, the scholars also observe a higher mortality rate in the group of patients prescribed benzodiazepine (Nguyen et al., 2017). The study’s attention to delirium-related symptoms and outcomes is its strength. In contrast, its low level of evidence and nonrandomized sampling are its weaknesses.

Based on the gathered evidence, the prescription of antipsychotics cannot be recommended. According to several systematic reviews, the use of antipsychotic drugs does not improve the wellbeing of patients. While some scholars show the benefits of these medications, their sources can be outdated or situational. Thus, the inconclusiveness of the data’s synthesis does not support antipsychotics as the first-line treatment option for delirium in elderly patients.

Conclusion

The treatment of delirium in older patients remains to be a topic of discussion in the field of healthcare research. This essay investigated the pharmacological treatments for delirium, focusing on antipsychotics. Key search terms for data collection included “age, adult, delirium, antipsychotics,” and the inclusion criteria required primary studies published five or fewer years ago. The selected five articles revealed inconclusive evidence, where some studies did not recommend antipsychotics, and others found these drugs to be effective. Overall, the impact of antipsychotics can be studied further, but, currently, these medications cannot be recommended for elderly patients with delirium.

Literature Matrix

Author/ Date	Research Questions/ Hypotheses	Methodology	Analysis and Results	Conclusions	Level of Evidence
Cerveira, Pupo, Santos, & Santos (2017)	How effective are various pharmacological and non-pharmacological treatments for elderly adults with delirium?	Systematic review	Among nonpharmacological approaches, none affect the duration of delirium, mortality, or hospitalization rates. In pharmacology, antipsychotics reduce the duration of delirium, improve cognitive abilities, reduce hospitalization length, and improve remission rates.	Pharmacological treatments are useful in treating the condition.	I
Lee, Kim, Ahn, & Kim (2017)	How effective are atypical antipsychotics (amisulpride, quetiapine, risperidone) for treating delirium in geriatric patients?	Cohort study, 4 groups	The researchers use the Korean version of the Delirium Rating Scale-Revised-98 and the Mini-mental Status Examination. They find no significant differences among the groups’ results.	Atypical antipsychotics do not improve patients’ delirium recovery, they are ineffective.	V
Mehta, Perreault, Luxenberg, Siddiqi, Hutton,… Burry (2018)	How effective are antipsychotics for treating delirium in hospitalized adults?	Systematic review	Antipsychotic treatment does not improve delirium’s severity, mortality, symptoms, length.	Antipsychotics and not recommended or treated.	I
Neufeld, Yue, Robinson, Inouye, & Needham (2016)	How effective are antipsychotics in preventing and treating delirium?	Systematic review	Antipsychotics do not change the duration, incidence, severity, hospitalization, or mortality of delirium.	The use of antipsychotics is not supported by evidence.	I
Nguyen, Malachane, & Minh (2017)	How are antipsychotics prescribed to elderly patients with delirium?	Retrospective cross-sectional study	Antipsychotics’ prescription leads to decreased duration of episodes. Some drugs (benzodiazepine) are associated with a higher rate of mortality.	Antipsychotics should be prescribed systematically to patients with delirium.	V

References

Cerveira, C. C. T., Pupo, C. C., Santos, S. D. S. D., & Santos, J. E. M. (2017). Delirium in the elderly: A systematic review of pharmacological and non-pharmacological treatments. Dementia & Neuropsychologia, 11(3), 270-275.

Eriksen, M. B., & Frandsen, T. F. (2018). The impact of patient, intervention, comparison, outcome (PICO) as a search strategy tool on literature search quality: A systematic review. Journal of the Medical Library Association: JMLA, 106(4), 420-431.

Holroyd-Leduc, J., & Reddy, M. (Eds.). (2012). Evidence-based geriatric medicine: A practical clinical guide. Hoboken, NJ: Blackwell Publishing.

Lee, M., Kim, T., Ahn, S., & Kim, J. L. (2017). Effectiveness of antipsychotics on delirium in elderly patients. Journal of Psychiatry, 20(4), 1000411.

Mehta, S., Perreault, M. M., Luxenberg, J. S., Siddiqi, N., Hutton, B., Fergusson, D. A.,… Burry, L. (2018). Antipsychotics for treatment of delirium in hospitalised non‐ICU patients. Cochrane Database of Systematic Reviews, (6), CD005594.

Neufeld, K. J., Yue, J., Robinson, T. N., Inouye, S. K., & Needham, D. M. (2016). Antipsychotics for prevention and treatment of delirium in hospitalized adults: A systematic review and meta‐analysis. Journal of the American Geriatrics Society, 64(4), 705-714.

Nguyen, P. V. Q., Malachane, A., & Minh, T. T. V. (2017). Antipsychotic prescription patterns in the management of delirium symptoms in hospitalized elderly patients. Proceedings of Singapore Healthcare, 26(4), 230-234.

Oh, E. S., Fong, T. G., Hshieh, T. T., & Inouye, S. K. (2017). Delirium in older persons: Advances in diagnosis and treatment. JAMA, 318(12), 1161-1174.

Resnick, B. (Ed.). (2016). Geriatric nursing review syllabus: A core curriculum in advanced practice geriatric nursing (5th ed.). New York, NY: American Geriatrics Society.

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