Objective: Delirium is a serious neuropsychiatric syndrome highly prevalent in medical/surgical settings and isrecognized as markedly underdiagnosed in all settings. It is known to increase mortality risk in acute hospital settings with overall mortality rates >37% in 6 months.
Delirium subtypes include hyperactive, hypoactive, and mixed. Usually behavioral sequelae trigger staff attention. Levkoff et al estimated that reducing delirium related length of stay for these patients would result in a $1-2 billion annual savings.
Current treatment options are limited in scope and research. Conventional antipsychotics have been the mainstay of behavioral treatment. There is an increasing trend towards using atypical agents without formal research support; ultimately both treatments can worsen delirium in the geriatric patient.
There is a small but interesting emergence of literature on anticonvulsant use in delirium.
Design: We conducted an open label case series (n=4) evaluating intravenous valproate efficacy in the treatment of delirium, based on a postulate that the final common delirium pathway may be a deficit in gabaergic tone.
Selection criteria:
> Age 65
Delirium unresponsive to antipsychotics or benzodiazepines within 48 hours
Delirium Rating Scale (DRS) of ≥19 at treatment initiation
Materials and Methods:
Patients were treated with intravenous valproate 20mg/kg BID via slow push
Concurrent antipsychotics/benzodiazepines were immediately discontinued
Daily DRS for first 4 treatment days
CGI rating daily
Results:
Within 48 hours, 75% symptom reduction in 3 patients, 30% in one patient
Cognition, psychomotor behavior, sleep-wake cycle disturbances showed the greatest changes
Conclusion: Evidence exists that gabaergic anticonvulsants may play a primary role in the suppression and/or treatment of delirium. Given deliriums known natural course, it is unlikely that course truncation occurred spontaneously. This open label study indicates that further research is necessary in this area. A larger scale double blind study would be in order.
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