Delirium in the primary care setting.

Delirium is a complex multifactorial neuropsychiatric syndrome with a broad range of cognitive and neurobehavioral symptoms. It is associated with major adverse events and poor outcome. Little is known about delirium in the primary care setting. A retrospective chart review was carried out for the identification of ICD-10 delirium cases presented in the regional medical office of a rural area in central Greece. Nine cases of delirium, mostly the hyperactive subtype, had been recorded. The patients tended to be elderly and suffering from dementia; infections were the underlying cause in most cases. All but one patient had been successfully treated in the primary care setting.

Efficacy and Safety of Adjunctive Cilostazol to Clopidogrel-Treated Diabetic Patients With Symptomatic Lower Extremity Artery Disease in the Prevention of Ischemic Vascular Events.

Background Type 2 diabetes mellitus is a risk factor for lower extremity arterial disease. Cilostazol expresses antiplatelet, anti-inflammatory, and vasodilator actions and improves the claudication intermittent symptoms. We investigated the efficacy and safety of adjunctive cilostazol to clopidogrel-treated patients with type 2 diabetes mellitus exhibiting symptomatic lower extremity arterial disease, in the prevention of ischemic vascular events and improvement of the claudication intermittent symptoms. Methods and Results In a prospective 2-arm, multicenter, open-label, phase 4 trial, patients with type 2 diabetes mellitus with intermittent claudication receiving clopidogrel (75 mg/d) for at least 6 months, were randomly assigned in a 1:1 ratio, either to continue to clopidogrel monotherapy, without receiving placebo cilostazol (391 patients), or to additionally receive cilostazol, 100 mg twice/day (403 patients). The median duration of follow-up was 27 months. The primary efficacy end point, the composite of acute ischemic stroke/transient ischemic attack, acute myocardial infarction, and death from vascular causes, was significantly reduced in patients receiving adjunctive cilostazol compared with the clopidogrel monotherapy group (sex-adjusted hazard ratio [HR], 0.468; 95% CI, 0.252-0.870; P=0.016). Adjunctive cilostazol also significantly reduced the stroke/transient ischemic attack events (sex-adjusted HR, 0.38; 95% CI, 0.15-0.98; P=0.046) and improved the ankle-brachial index and pain-free walking distance values (P=0.001 for both comparisons). No significant difference in the bleeding events, as defined by Bleeding Academic Research Consortium criteria, was found between the 2 groups (sex-adjusted HR, 1.080; 95% CI, 0.579-2.015; P=0.809). Conclusions Adjunctive cilostazol to clopidogrel-treated patients with type 2 diabetes mellitus with symptomatic lower extremity arterial disease may lower the risk of ischemic events and improve intermittent claudication symptoms, without increasing the bleeding risk, compared with clopidogrel monotherapy. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02983214.

Atypical antipsychotics in the treatment of delirium.

Delirium is common in all medical settings. Atypical antipsychotics are increasingly used for the management of delirium symptomatology but their effectiveness has not been systematically studied. The aim of the present study was therefore to provide an up-to-date review on the use of atypical antipsychotics in the treatment of delirium. A search was conducted of the databases of MEDLINE, PsycINFO and EMBASE from 1997 to 2008 for English-language articles using the key words 'delirium' and the names of all the atypical antipsychotics. A total of 23 studies were used for this review. Fifteen of the studies were single-agent trials. Four studies were comparison trials, including one double-blind trial, and four studies were retrospective, including three comparison studies. All studies reported improvement of delirium symptomatology after the administration of atypical antipsychotics. No study included a placebo group. Other limitations included sample heterogeneity, small sample size, different rating scales for delirium, and lack of adequate controls. The improvement in delirium was observed within a few days after treatment initiation and the doses given were relatively low. Atypical antipsychotics were well tolerated, but safety was not evaluated systematically. Atypical antipsychotics appear to be effective and safe in symptomatic treatment of delirium but the evidence is limited and inconclusive. There are no double-blind, placebo-controlled studies assessing the efficacy and safety of these agents in delirium. Further research is needed with well-designed studies.

Mental Health Care Delivery for Older Adults in Rural Greece: Unmet Needs.

Mental disorders may go unrecognized and undertreated in older adults. This is the rationale for the launch of specialized mental health services for the elderly in high resourced settings. Rural areas, however, do not receive adequate mental health care owing to socioeconomic and geographical reasons, and this is the case of rural Greece, where research on mental health of the elderly is scarce. This article discusses the challenges of providing mental health care for older adults in rural Greece and the available options. Care can be delivered through the existing rural mental health services that are the mobile mental health units and through the primary care physicians. Training in psychogeriatrics for the personnel of the former and in mental health for the latter is warranted.

Recent Insights on Prevalence and Corelations of Hypoactive Delirium.

Delirium is a complex neuropsychiatric syndrome which is common in all medical settings. It often goes unrecognized due to difficulties in the detection of its hypoactive variant. This review aims to provide an up-to-date account on recent research on hypoactive delirium (HD). Thirty-eight studies, which were conducted in various clinical settings, including the Intensive Care Unit (ICU), were included in this review. Those studies involved recent research that has been published during the last 6 years. Prevalence of HD was found to vary considerably among different settings. HD seems to be more common in critically ill patients and less common in patients examined by consultation-liaison psychiatric services and in mixed patient populations. The presence of HD in ICU patients was associated with higher short- and long-term mortality and other adverse outcomes, but no such association was reported in other settings. Research on other possible associations of HD with clinical variables and on symptom presentation yielded inconclusive results, although there is some evidence for a possible association of HD with benzodiazepine use. There are several methodological issues that need to be addressed by future research. Future studies should examine HD in the primary care setting; treatment interventions should also be the objective of future research.