Benzodiazepines for treating patients with delirium (excludi | Figure 1

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Benzodiazepines for treating patients with delirium (excluding patients in intensive care units)

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The use of benzodiazepines to treat adults with delirium, excluding patients being cared for in intensive care units (ICU)

Background: Delirium is a serious complication of many illnesses, which occurs most commonly in young children and older adults. It usually presents as a sudden change in a patient's behaviour or mental state. Another name for it is ‘acute confusional state.’ Patients with delirium may not know where they are, what time it is, or what is happening to them. They may have frightening experiences, such as vivid hallucinations. They may become either restless or lethargic and inactive. Delirium can be very distressing for patients and for those who are caring for them. Studies show that about a third of patients on general medical wards develop delirium. It is a frequent complication after surgery (e.g. it happens in up to 60% of people who have surgery for a hip fracture). The effects of delirium can last for a long time. For older people, it can lead to longer hospital stays and it has been associated with increased risks of death, disability, loss of independence, and later dementia. It adds significantly to healthcare costs.

Benzodiazepines are medicines that are often used as sedatives. Sometimes, healthcare workers prescribe them to treat delirium when other strategies have not helped. Currently, it is not clear if benzodiazepines are an effective treatment for patients with delirium or whether they can harm them.

Review question: Patients need more and better treatment options for delirium. We wanted to know if benzodiazepines are a helpful treatment option for delirium in any healthcare setting except ICU (patients in ICU are very sick and they may need different kinds of treatment). To find the best answer, we looked for studies where the investigators compared any benzodiazepine to another medicine, or to a dummy medicine that does not contain any active ingredients (placebo). To make the comparison fair, patients in the studies must all have had the same random chance (like the flip of a coin) to receive the benzodiazepine or the other treatment.

Search date: We searched the medical literature up to 10 April 2019.

Study characteristics: We found only two small studies which were suitable to include in our review. In one study, the 58 patients who took part all had advanced cancer. They were treated in a specialist palliative care unit. The study compared lorazepam (a benzodiazepine) to placebo. In the second study, the 30 patients all had AIDS (acquired immune deficiency syndrome). They were treated in general medical wards. This study compared lorazepam to two different drugs that are sometimes used to treat delirium.

Key results: We did not find any important benefits for patients who took lorazepam instead of the other treatment in these two studies. Patients who took it did not have better outcomes. We do not have any definite evidence that lorazepam was more harmful than the other treatment, but, in the study of patients with AIDS, the researchers stopped treating people with lorazepam after the first six people who took it all had serious side effects. Because there were only two suitable studies and both had small numbers of patients in them, we cannot draw any firm conclusions. Currently, there is no good evidence to tell us whether or not benzodiazepines should be used to treat patients with delirium. Clinicians, patients, and carers should be aware of the lack of evidence. We think there is a need for more research, and particularly for studies that involve older patients in general medical and surgical settings, where most delirium is treated.

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\ \ How accurate is the CAM‐ICU tool for the diagnosis of delirium in adult patients admitted to critical care units?\ Key messages\ Our review suggests that the CAM‐ICU is a reasonable test to look for delirium in critical care settings. The test may be especially good for ruling out delirium. If the CAM‐ICU suggests no delirium, it is unlikely the person has delirium.\ What is the CAM‐ICU?\ The Confusion Assessment Method for the Intensive Care Unit (CAM‐ICU) is a test to look for delirium. It is based on a series of questions and commands that are designed to detect the features of delirium.\ Certain aspects of the CAM‐ICU test make it suitable for busy critical care settings. The CAM‐ICU test can be completed even if the patient being tested can’t speak. The CAM‐ICU is quick to perform and requires minimal training, thus it can be used by any member of the healthcare team.\ What was studied in the review?\ We reviewed studies that assessed the accuracy of the CAM‐ICU when used in a critical care setting. We included those studies that compared the results of the CAM‐ICU test, performed by a CAM‐ICU trained professional, with a more detailed ‘gold standard’ diagnostic assessment.\ What are the main results of the review?\ We included 25 studies with a total of 2817 participants. CAM‐ICU correctly identified patients with delirium about 78% of the time. The test was better at identifying those without delirium, giving correct results about 95% of the time.\ If the CAM‐ICU was applied to a group of 100 patients in critical care, where 40% (40) of them have delirium, it is estimated that the CAM‐ICU tool would correctly detect around 31 patients with delirium and miss nine cases. The CAM‐ICU would suggest that three patients have delirium when they do not.\ How reliable are the results of the studies in the review?\ Despite the low risk of bias and the high numbers of participants in the included studies, we are uncertain about the results due to differences among studies in the way the test was applied and in the interpretation of the ‘gold standard’ comparison.\ To whom do the results of this review apply?\ We only looked at papers that studied the CAM‐ICU test when used in a critical care setting. CAM‐ICU is used in other healthcare settings, but that was not the focus of this review.](https://app.figure1.com/case-detail/027547d0-96c6-406e-b58d-0ebbeee71550)

\ \ April 7, 2020\ A paper published in JAMA on April 6th describes the outcomes of patients with confirmed SARS-CoV-2 infection who were admitted to Intensive Care Units in Lombardy, Italy. Of the 1,591 patients admitted to the ICUs, most were men (82 percent) and the average age was 63 years old. Almost all patients—99 percent—required at least some help with breathing, including 88 percent who required a mechanical ventilation (a breathing machine). At the time of the study, 26 percent of the patients followed in this study had already died, while another 58 percent remain in the ICU.\ This study is notable for several reasons. First, this study represents the largest group of ICU patient outcomes described since the start of the covid-19 pandemic. Second, the authors shared intricate details in this publication, providing important insights into the needs of covid-19 patients ICUs. Finally, the results provide further evidence that older patients with chronic disease (high blood pressure, lung disease, etc) tend to fare poorly when they become sick with covid-19. While this study may not immediately provide “practice-changing” information for emergency physicians and other hospital providers, it is a stark reminder that older patients with multiple medical problems may require higher levels of medical care.\ Shared with permission from Brief19, a daily review of #covid-19 research and policy.](https://app.figure1.com/case-detail/14d88df0-3db6-43b2-bb27-60cb5d296e85)

\ \ Background\ Delirium is common in people with a terminal illness. A person experiencing delirium may be confused, lack concentration, have disturbed patterns of sleep and waking, and experience hallucinations. Delirium can start suddenly and can cause distress to both the person and their family. Delirium may be caused by the underlying disease with which the person is affected, or as a side effect of drugs or other symptoms. Often it is not clear why a person has delirium. The multifaceted nature of delirium makes its management challenging. When it is not possible to identify the underlying cause, drug treatments are sometimes used to manage the symptoms.\ Study characteristics\ The aim of this review was to find out what we know about the effectiveness and side effects of drugs in the management of delirium in adults with a terminal illness. For the purpose of this review, terminally ill adults includes anyone with an advanced progressive illness such as advanced cancer, advanced dementia or organ failure, as well as those receiving hospice and end‐of‐life care. We compared drug therapy with placebo (a substance with no known active effect), usual care, or any other drug or non‐drug treatment.\ Key results\ Our search to July 2019 found four trials, involving 399 adults in total. Participants had advanced cancer (three studies) or advanced AIDS (one study), and all had symptoms of delirium. The drugs evaluated were antipsychotics (three studies) or benzodiazepines (one study), compared to placebo or each other, on their own or in combination with another drug or placebo.\ Most studies reported the outcomes we deemed most important: delirium symptoms, agitation, and adverse events (side effects).\ It was not possible to combine the data from different studies due to a lack of similarity between them. We found low‐quality evidence that certain drugs (haloperidol and risperidone) may slightly worsen delirium symptoms for terminally ill adults with mild‐ to moderate‐severity delirium. We found moderate‐quality evidence that haloperidol probably slightly increases adverse side effects for people with mild‐ to moderate‐severity delirium.\ Quality of the evidence\ We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. We found no high‐quality evidence. This was due to the small number of people taking part, the number of people dropping out of the studies, and the small number of studies.\ Conclusion\ We found low‐quality evidence that, compared to placebo, drug therapy (specifically haloperidol and risperidone) may slightly worsen delirium symptoms in terminally ill people with delirium of mild to moderate severity. We found low‐ to moderate‐quality evidence that these drugs may slightly increase adverse side effects. Given the small numbers of studies and participants on which current evidence is based, further research is essential.](https://app.figure1.com/case-detail/41b78176-e103-49d6-ab70-21a1a681df71)

\ \ Do patients manage their healthcare better if they can access their electronic health records?\ \ What are electronic health records?\ Healthcare providers maintain health‐related information about a patient in an electronic health record, which is held in a digital form and is accessed by a computer. Healthcare professionals use these records to access all health‐related information for a patient's care, whenever and wherever they need it. Information may include a person's medical history, medicines, allergies, test results, and immunisation history.\ Some healthcare providers let patients see their own electronic health records, usually by giving them web‐based access. Patients may also be offered other web‐based services, such as health‐related reminders, secure messaging, and general educational health information.\ Why we did this Cochrane Review\ Access to electronic health records might encourage patients to talk with a healthcare professional about their health and potential treatments, and might help them to take part in decision‐making. We wanted to find out whether access to electronic health records benefits patients or causes any potentially unwanted effects.\ What did we do?\ We searched for studies that looked at patients’ access to electronic health records. We also looked for studies where access came with extra services. 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Five studies were conducted in doctors' offices and five in hospital clinics. People taking part in the studies were followed up for three months to two years. Two studies were funded in part by pharmaceutical companies.\ The studies focused on patients with type 2 diabetes (five studies), asthma (one study), glaucoma (one study), congestive heart failure (one study), and hypertension (one study); one study focused on patients who visited their doctor for any reason.\ Studies compared usual care plus access to electronic health records against usual care alone. 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