College of Psychiatric and Neurologic Pharmacists

Delirium is a state of acute confusion resulting from a general medical condition that can last from hours to months, often fluctuates in severity and presentation, and may include a variety of psychiatric symptoms. It is particularly common in the elderly and those with pre-existing cognitive impairment or brain injury. Delirium is a predictor of multiple adverse outcomes, including functional and cognitive decline, increased length of hospitalization, and mortality.

Acetylcholine deficits have been proposed as the final common pathway to delirium by some investigators, but the pathophysiology of delirium is not well understood. Despite this uncertainty, it is clear that anticholinergic drugs can cause or contribute to delirium. Multiple challenge studies, epidemiologic studies, and studies examining serum anticholinergic activity in delirium provide evidence in this regard. People with dementia are highly susceptible to the cognitive and psychiatric adverse effects of anticholinergics and may experience cognitive symptoms and behavioral disturbances as a result of anticholinergic exposure.

The primary treatment for delirium is to correct the underlying cause and provide a safe and supportive environment while it resolves. Antipsychotics are the mainstay of symptomatic treatment, though adverse effects need to be considered in high risk populations such as those with dementia. Pharmacists can help manage and prevent delirium by reviewing medications and recommending discontinuation of drugs that might be contributing to cognitive impairment. Prior studies have shown that anticholinergic medications are frequently prescribed to people with dementia. Given that these patients have a high risk of experiencing delirium and are sensitive to these medications, efforts to eliminate anticholinergic prescribing in this group may help reduce the burden of delirium.

1. Identify delirium and its contributing causes.
2. Describe populations at risk of delirium and differentiate symptoms of anticholinergic delirium to symptoms of other deliriums and also to symptoms of dementia.
3. Distinguish the contribution of anticholinergic medications to delirium and also the exquisite sensitivity of anticholinergic medications in dementia patients.
4. Recognize the pharmacist’s role in assessing anticholinergic burden.
5. Describe management and preventive strategies for delirium and associated agitation.

Activity Dates: 04/21/2009 - 04/21/2012
ACPE Contact Hours: 1.0
ACPE Number: 0284-0000-09-011-H01-P
Nursing Credit Reminder: Note that ACPE and ACCME credit is accepted for certification renewal.

This course is provided online at cpnp.org and consists of the speaker audio and slides. A PDF file of the slides is also provided and access is available to participants indefinitely although ACPE credit is available only through the course expiration date.

Participants in this course must complete an examination and achieve a score of 60% or greater. Successful completion of the course also requires the completion of a course evaluation. ACPE statements of credit can be retrieved by participants online at cpnp.org immediately upon successful completion of the course.

If you are a pharmacist, nurse practitioner or other healthcare professional involved in the medication therapy management of psychiatric and/or neurological patients, we invite you to participate in this online course.

This programming was supported in part by grants from Bristol-Myers Squibb, Forest Laboratories, Inc., Lilly, Schering-Plough, Cyberonics, and Shire.