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drugs commonly producing delirium

Etiology: 1) drugs with anticholinergic activity# a) see drugs with anticholinergic activity for relative potencies b) parasympatholytics - atropine - scopolamine - H1 receptor antagonists: diphenhydramine, promethazine [9] 2) neuroleptics with anticholinergic activity [2] a) chlorpromazine b) thioridazine c) antipsychotics (MKSAP19) [10] c) no increased risk [3] 3) antidepressants with anticholinergic activity a) tricyclic antidepressants b) lithium c) SSRI d) atypical antidepressants 4) histamine H2 receptor antagonists with anticholinergic activity a) uncertainty regarding H2-receptor antagonists (GRS9) [5] b) should be avoided in older adults (GRS9) [5] c) cimetidine has 86% of anticholinergic activity of atropine 5) narcotic analgesics* a) morphine b) meperidine c) oxycodone 6) sedative-hypnotics 7) benzodiazepines* a) triazolam b) alprazolam 8) Parkinsonian agents a) amantadine b) levodopa/carbidopa (Sinemet) 3) dopamine agonists (pergolide, bromocryptine) c) benztropine (anticholinergic agent) 9) diuretics 10) antiarrhythmics a) quinidine b) digoxin 11) anti-inflammatory agents a) NSAIDs b) glucocorticoids 12) anticonvulsants - barbiturates, phenytoin 13) general anesthetics - depth of anesthesia is risk factor [4.5] 14) alcohol 15) fluoroquinolones [10] # most common in elderly [2] * drugs most associated with delirium were opioids, benzodiazepines, dihydropyridines, & possibly, antihistamines [3] - only antihistamine specifically implicated is diphenhydramine (GRS9) [5] * prehospital statin therapy with continued statin therapy during hospitalization may diminish risk of delirium in critically ill elderly [7,8]

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drugs with anticholinergic activity

References

  1. Francis J, J Am Geriatric Soc 40:829, 1992
  2. Geriatrics at Your Fingertips, Reuben et al (eds) American Geriatrics Society, Excerpta Medica, Belle Mead, NJ, 2001
  3. Clegg A, Young JB. Which medications to avoid in people at risk of delirium: a systematic review. Age Aging 2011; 40:23-29. PMID: 21068014
  4. Sieber FE, Zakriya KJ, Gottschalk A et al Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair. Mayo Clin Proc. 2010 Jan;85(1):18-26. Erratum in: Mayo Clin Proc. 2010 Apr;85(4):400. Dosage error in article text. PMID: 20042557
  5. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  6. Kalisch Ellett LM, Pratt NL, Ramsay EN, et al. Multiple anticholinergic medication use and risk of hospital admission for confusion or dementia. J Am Geriatr Soc. 2014;62(10):1916-1922 PMID: 25284144
  7. Morandi A, Hughes CG, Thompson JL et al Statins and delirium during critical illness: a multicenter, prospective cohort study. Crit Care Med. 2014 Aug;42(8):1899-909. PMID: 24810528 Free PMC Article
  8. Page VJ, Davis D, Zhao XB Statin use and risk of delirium in the critically ill. Am J Respir Crit Care Med. 2014 Mar 15;189(6):666-73. PMID: 24417431 Free PMC Article
  9. Rothberg MB, Herzig SJ, Pekow PS et al Association between sedating medications and delirium in older inpatients. J Am Geriatr Soc. 2013 Jun;61(6):923-30. PMID: 23631415
  10. Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022