Jin H Han1,2,3, Alex Chen4, Eduard E Vasilevskis1,2,5, John F Schnelle1,2,6, E Wesley Ely1,2,7, Rameela Chandrasekhar8, Ryan D Morrison9, Timothy P Ryan9, J Scott Daniels9, Jeff J Sutherland9, Sandra F Simmons1,2,6. 1. Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee. 2. Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee. 3. Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee. 4. Department of Emergency Medicine, Division of Medical Toxicology and Precision Medicine, University of Arizona College of Medicine, Phoenix, Arizona. 5. Department of Medicine, Division of General Internal Medicine and Public Health, Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee. 6. Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee. 7. Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee. 8. Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee. 9. Precera Bioscience, Inc., Franklin, Tennessee.
Abstract
OBJECTIVES: Polypharmacy is associated with delirium, but the mechanisms for this connection are unclear. Our goal was to determine the frequency of supratherapeutic psychotropic drug levels (SPDLs) in older hospitalized patients and if it is associated with the duration of emergency department (ED) delirium. DESIGN: Secondary analysis of a prospective cohort study. SETTING: Tertiary care academic medical center. PARTICIPANTS: ED patients 65 years or older who were admitted to the hospital. MEASUREMENTS: Delirium was assessed in the ED and during the first 7 days of hospitalization using the modified Brief Confusion Assessment Method. Drug concentrations were determined in serum samples collected at enrollment via a novel platform based on liquid chromatography-tandem mass spectrometry capable of identifying and quantitating 78 clinically approved medications including opioids, benzodiazepines, antidepressants, antipsychotics, and amphetamines. Patients with serum psychotropic drug concentrations above established reference ranges were considered supratherapeutic and have a SPDL. We performed proportional odds logistic regression to determine if SPDLs were associated with ED delirium duration adjusted for confounders. Medical record review was performed to determine if the doses of medications associated with SPDLs were adjusted at hospital discharge. RESULTS: A total of 158 patients were enrolled; of these, 66 were delirious in the ED. SPDLs were present in 11 (17%) of the delirious and 4 (4%) of the non-delirious ED patients. SPDLs were significantly associated with longer ED delirium duration (adjusted proportional odds ratio = 6.0; 95% confidence interval = 2.1-17.3) after adjusting for confounders. Of the 15 medications associated with SPDLs, 9 (60%) were prescribed at the same or higher doses at the time of hospital discharge. CONCLUSION: SPDLs significantly increased the odds of prolonged ED delirium episodes. Approximately half of the medications associated with SPDLs were continued after hospital discharge at the same or higher doses. J Am Geriatr Soc 67:2387-2392, 2019.
OBJECTIVES: Polypharmacy is associated with delirium, but the mechanisms for this connection are unclear. Our goal was to determine the frequency of supratherapeutic psychotropic drug levels (SPDLs) in older hospitalized patients and if it is associated with the duration of emergency department (ED) delirium. DESIGN: Secondary analysis of a prospective cohort study. SETTING: Tertiary care academic medical center. PARTICIPANTS: ED patients 65 years or older who were admitted to the hospital. MEASUREMENTS: Delirium was assessed in the ED and during the first 7 days of hospitalization using the modified Brief Confusion Assessment Method. Drug concentrations were determined in serum samples collected at enrollment via a novel platform based on liquid chromatography-tandem mass spectrometry capable of identifying and quantitating 78 clinically approved medications including opioids, benzodiazepines, antidepressants, antipsychotics, and amphetamines. Patients with serum psychotropic drug concentrations above established reference ranges were considered supratherapeutic and have a SPDL. We performed proportional odds logistic regression to determine if SPDLs were associated with ED delirium duration adjusted for confounders. Medical record review was performed to determine if the doses of medications associated with SPDLs were adjusted at hospital discharge. RESULTS: A total of 158 patients were enrolled; of these, 66 were delirious in the ED. SPDLs were present in 11 (17%) of the delirious and 4 (4%) of the non-delirious ED patients. SPDLs were significantly associated with longer ED delirium duration (adjusted proportional odds ratio = 6.0; 95% confidence interval = 2.1-17.3) after adjusting for confounders. Of the 15 medications associated with SPDLs, 9 (60%) were prescribed at the same or higher doses at the time of hospital discharge. CONCLUSION: SPDLs significantly increased the odds of prolonged ED delirium episodes. Approximately half of the medications associated with SPDLs were continued after hospital discharge at the same or higher doses. J Am Geriatr Soc 67:2387-2392, 2019.
Authors: Jin H Han; Eduard E Vasilevskis; Rameela Chandrasekhar; Xulei Liu; John F Schnelle; Robert S Dittus; E Wesley Ely Journal: J Am Geriatr Soc Date: 2017-03-06 Impact factor: 5.562
Authors: C Hiemke; N Bergemann; H W Clement; A Conca; J Deckert; K Domschke; G Eckermann; K Egberts; M Gerlach; C Greiner; G Gründer; E Haen; U Havemann-Reinecke; G Hefner; R Helmer; G Janssen; E Jaquenoud; G Laux; T Messer; R Mössner; M J Müller; M Paulzen; B Pfuhlmann; P Riederer; A Saria; B Schoppek; G Schoretsanitis; M Schwarz; M Silva Gracia; B Stegmann; W Steimer; J C Stingl; M Uhr; S Ulrich; S Unterecker; R Waschgler; G Zernig; G Zurek; P Baumann Journal: Pharmacopsychiatry Date: 2017-09-14 Impact factor: 5.788
Authors: Christophe Hein; Adrien Forgues; Antoine Piau; Agnès Sommet; Bruno Vellas; Fati Nourhashémi Journal: J Am Med Dir Assoc Date: 2014 Impact factor: 4.669
Authors: E W Ely; S K Inouye; G R Bernard; S Gordon; J Francis; L May; B Truman; T Speroff; S Gautam; R Margolin; R P Hart; R Dittus Journal: JAMA Date: 2001-12-05 Impact factor: 56.272