The challenge of managing severe delirium: an observational study of the effects of pharmacological and supportive care on delirium duration and resolution in 602 patients

Abstract

Background: Delirium is the most common neuropsychiatric disorder seen in hospitalised patients. Current guidelines recommend only using antipsychotics with distressed patients. Nonetheless, in routine clinical practice, multiple psychotropics are commonly administered. More evidence on the short-term benefits of various management approaches in patients with delirium is required. Methods: In this observational cohort study, 602 delirious patients were followed for twenty days. Supportive care was provided to all patients in addition to either no psychotropic therapy, monotherapy, dual therapy, or polytherapy defined as three or more psychotropic drugs. The effectiveness of interventions regarding delirium resolution and symptom severity was determined by Cox proportional hazards regression and generalized estimating equation models. Results: Psychotropics were commonly used to manage delirium. In total, 12.1% of patients received polytherapy, 37.2% dual therapy, 37.7% monotherapy, and 12.1% supportive care alone (i.e., almost half of the patients received ≥ two psychotropics). Patients who received polytherapy had higher initial baseline delirium severity and exposed the mixed subtype more often; with the latter delirium lasted longer and recovery was less frequent than in mild delirium. Providing supportive care alone in mild delirium was superior to all psychotropic approaches. Conclusions: In routine clinical practice, the use of multiple psychotropics is common. In our study, however, despite combined supportive management and polypharmacy, patients with severe delirium suffer longer from delirium and have lower resolution rates. For the management of patients with mild delirium supportive care alone can be considered. When psychotropics are considered, single psychotropics and dose optimisation are recommended. These findings underline the challenge of managing severe delirium.