Psychosomatics 44:437-438, October 2003
© 2003 The Academy of Psychosomatic Medicine
Donepezil for Postoperative Delirium
Ondria C. Gleason, M.D., Tulsa, Okla.
TO THE EDITOR: Delirium, a common problem in the general hospital, can result in substantial morbidity and mortality. The definitive treatment of delirium is identification and correction of the underlying etiology; however, treatment of the associated psychiatric symptoms and cognitive impairment may be necessary. I report on the use of donepezil in the management of delirium after hip arthroplasty.
Case History
Ms. A, a 74-year-old white woman who was diagnosed with late-onset bipolar affective disorder at the age of 69, came to the hospital after sustaining a right hip fracture. In the emergency department, she was crying, alert, and fully oriented. She received 4 mg of intravenous morphine sulfate for pain. She slept well and answered questions appropriately the next morning but was drowsy. After hip arthroplasty, she was awake but verbally unresponsive. The next day, she continued to exhibit a blank expression, lethargy, and minimal verbal responses. A psychiatric consultation was obtained 2 days after her operation because of her verbal unresponsiveness.
At the consultation, she displayed a fluctuating level of consciousness, was disoriented to place and time, had poor attention, uttered only a few words and short phrases, but was pleasant and no longer agitated. She did not report feeling depressed, manic, or anxious and was without auditory or visual hallucinations. Her score on the Mini Mental State Examination was 10 out of 30. Her performance on the clock-drawing task was poor and extremely delayed because of her fluctuating level of consciousness and preservation.
Ms. A's daughter reported similar episodes of withdrawal, mutism, anorexia, and irritability in the past whenever her medications were discontinued. Ms. A had no psychiatric history until she developed an episode of depression, which required hospitalization at the age of 68. Within the next year, she sustained a left hip fracture that was followed by an episode of mania. She was diagnosed with late-onset bipolar affective disorder. It is unknown whether the possibility of secondary mania was considered. Ms. A was hospitalized for a second episode of depression at the age of 71.
Her psychiatrist recommended obtaining an EEG and a computerized tomography scan of Ms. A's head, which revealed diffuse slowing and mild small vessel ischemic changes, respectively. The EEG findings supported the diagnosis of delirium, and Ms. A was given donepezil, 5 mg/day.
The next day, Ms. A was better but still confused and sleepy. The second day, she was alert and conversant, discussed recent events, and displayed insight into her recent confusion. Her sleep remained disrupted. Three days after the initial consultation, she was alert, fully oriented, displayed good eye contact and normal psychomotor activity, but her short-term memory was poor, and she had difficulty naming objects. Her score on the Mini Mental State Examination was 20 of 30. She accurately performed the clock-drawing task. On the fourth day, she was alert and oriented, had a full affect, and was walking better. By the fifth day, she was fully alert, lucid, and was discharged to her assisted-living facility. She continued to take donepezil, 5 mg/day.
Discussion
Haloperidol has been the most studied medication for the symptomatic management of delirium. There are a few case reports and small studies demonstrating the usefulness of the newer atypical antipsychotics, risperidone,1–3 olanzapine,4–6 quetiapine,7,8 and ziprasidone,9 for delirium. One larger, open-label, prospective study suggested the usefulness of olanzapine for cancer patients with delirium but also identified several factors associated with a poorer response to the drug. Those factors included older age (>70 years), a history of dementia, CNS metastases, hypoxia, hypoactive subtype of delirium, and more severe delirium (a score on the Memorial Delirium Assessment Scale >23).10
Kaufer et al.11 reported on the use of donepezil for delirium-like features of Lewy body dementia, in which cholinergic deficiency is greater than in Alzheimer's disease.12 The clinical presentation of Lewy body dementia can be similar to that of delirium, with fluctuating levels of attention, visual hallucinations, and extrapyramidal symptoms. Wengel et al.13,14 reported two cases of successful use of donepezil in delirium in patients with dementia, and Burke et al.15 reported on its use for delirium in a patient without dementia. Conversely, Kawashima and Yamada16 reported a case of delirium occurring in a 65-year-old Japanese man 3 days after the initiation of donepezil for Alzheimer's dementia.
Further study on the potential usefulness of donepezil in the management of delirium is needed to sort out whether or not certain classes of patients may be responsive to cholinergic intervention of this nature.
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B. Liptzin, A. Laki, J. L. Garb, R. Fingeroth, and R. Krushell
Donepezil in the Prevention and Treatment of Post-Surgical Delirium
Am J Geriatr Psychiatry,
December 1, 2005;
13(12):
1100 - 1106.
[Abstract]
[Full Text]
[PDF]
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