Volume 67, Issue 11 p. 2387-2392
Brief Report

Supratherapeutic Psychotropic Drug Levels in the Emergency Department and Their Association with Delirium Duration: A Preliminary Study

Jin H. Han MD, MSc

Corresponding Author

Jin H. Han MD, MSc

Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee

Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee

Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee

Address correspondence to Jin H. Han, MD, MSc, Vanderbilt University Medical Center, Department of Emergency Medicine, 312 Oxford House, Nashville, TN 37232-4700. E-mail: [email protected]Search for more papers by this author
Alex Chen MD

Alex Chen MD

Department of Emergency Medicine, Division of Medical Toxicology and Precision Medicine, University of Arizona College of Medicine, Phoenix, Arizona

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Eduard E. Vasilevskis MD, MPH

Eduard E. Vasilevskis MD, MPH

Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee

Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee

Department of Medicine, Division of General Internal Medicine and Public Health, Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee

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John F. Schnelle PhD

John F. Schnelle PhD

Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee

Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee

Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee

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E. Wesley Ely MD, MPH

E. Wesley Ely MD, MPH

Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee

Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee

Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee

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Rameela Chandrasekhar PhD

Rameela Chandrasekhar PhD

Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee

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Ryan D. Morrison BA

Ryan D. Morrison BA

Precera Bioscience, Inc., Franklin, Tennessee

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Timothy P. Ryan PhD

Timothy P. Ryan PhD

Precera Bioscience, Inc., Franklin, Tennessee

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J. Scott Daniels PhD

J. Scott Daniels PhD

Precera Bioscience, Inc., Franklin, Tennessee

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Jeff J. Sutherland PhD

Jeff J. Sutherland PhD

Precera Bioscience, Inc., Franklin, Tennessee

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Sandra F. Simmons PhD

Sandra F. Simmons PhD

Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee

Geriatric Research, Education, and Clinical Center, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care Center, Nashville, Tennessee

Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee

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First published: 10 September 2019
Citations: 1
This abstract was presented at the American Delirium Society 2017 Annual Meeting, Baltimore, MD.

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