Is there evidence for using anticonvulsants in the prevention and/or treatment of delirium among older adults?

Abstract

Objective: This systematic review aims to identify published randomized controlled trials (RCTs) that evaluated the use of anticonvulsants for the prevention and/or treatment of delirium among older adults. Methods: A comprehensive search of databases: MEDLINE ALL (Ovid), Embase (Ovid), PsycINFO (Ovid), Web of Science Core Collection and Cochrane Central Register of Controlled was conducted. Results: The search identified four RCTs that evaluated the use of anticonvulsants among older adults with delirium. One RCT evaluated the perioperative use of gabapentin among individuals undergoing spinal surgery and the development of postoperative delirium. One RCT evaluated the relationship between the use of perioperative gabapentin and the development of postoperative delirium among individuals undergoing spinal surgery and hip and knee arthroplasty. Two post-hoc analyses of RCTs evaluated the use of gabapentin and pregabalin among individuals undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). The perioperative use of gabapentin reduced the incidence of postoperative delirium among older adults undergoing spinal surgery. The perioperative use of gabapentin did not reduce the rates, severity or duration of postoperative delirium among older adults who were undergoing spine and hip and knee arthroplasty. The perioperative use of gabapentin did not reduce the incidence or duration of postoperative delirium among older adults undergoing elective TKA. The perioperative use of pregabalin did not reduce the incidence of postoperative delirium among older adults undergoing elective THA. Gabapentin and pregabalin were well tolerated among the individuals enrolled in these trials. There were no RCTs identified that evaluated the use of other anticonvulsants for the prevention and/or treatment of delirium among older adults. Conclusions: Based on current evidence, the routine use of anticonvulsants for the prevention and/or treatment of delirium among older adults cannot be recommended.

Management of delirium in older adults: challenges and opportunities

“…Inouye's chart abstraction tool (used in two of the studies identified by Gupta et al, 2022) has been shown to have a sensitivity of 74% and specificity of 83% using the CAM as the gold standard (Inouye et al, 2005). However, dementia has been shown to be associated with false positive delirium ratings using this chart abstraction tool, with a dementia diagnosis present in 20% of the false positive ratings (vs. 9% of the true negative ratings) (Inouye et al, 2005).…”

“…As Gupta et al (2022) point out in their conclusion, there is no high-quality evidence supporting the use of anticonvulsants in preventing or treating delirium in hospitalized older adults. Their review highlights some challenges in the delirium literature as a whole.…”

“…In their systematic review published in this issue of International Psychogeriatrics, Gupta et al (2022) note that anticonvulsants are used clinically to manage delirium, with observational studies suggesting some benefit in the use of valproic acid to treat delirium. However, as the authors note, these studies were conducted in adults across the lifespan and the findings may not generalize to older adults, the population at highest risk of delirium.…”

“…In order to critically appraise the evidence for this class of medication in managing delirium in older adults, they performed a systematic review with the goal of identifying randomized controlled trials (RCTs) examining the use of anticonvulsants to prevent or treat delirium in this population. Gupta et al (2022) identified findings from only four RCTs (two primary analyses and two post-hoc analyses) in their review, all involving gabapentinoids (pregabalin or gabapentin), and all in patients undergoing orthopedic or spinal surgeries. The putative mechanism of gabapentinoids in delirium prevention in this population is primarily via opioidsparing (Fabritius et al, 2017).…”

Pharmacotherapy in geriatric psychiatry: what we know and what we need to know

“…However, it is necessary to examine the data specifically in older patients who are at a considerably higher risk of delirium than younger adults. Gupta et al (2022) conducted a systematic review of RCTs of anticonvulsants to prevent or treat delirium in geriatric population. They identified only four RCTs, all involving gabapentinoids (pregabalin or gabapentin) in patients undergoing orthopedic or spinal surgeries.…”