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01.12.2018 | Letter | Ausgabe 1/2018 Open Access

Critical Care 1/2018

Gender differences in the use of atypical antipsychotic medications for ICU delirium

Zeitschrift:
Critical Care > Ausgabe 1/2018
Autoren:
Kunal Karamchandani, Robert S. Schoaps, Jillian Printz, Jeffrey M. Kowaleski, Zyad J. Carr
Abbreviations
AAP
Atypical antipsychotic medications
ICU
Intensive care unit
Intensive care unit (ICU) delirium, an acute fluctuating disturbance of cognition associated with critical illness, is associated with increased mortality, ICU length of stay, mechanical ventilation, and hospital costs [ 13]. Despite a link to increased long-term mortality, atypical antipsychotic medications (AAP) are frequently administered for the treatment of ICU delirium. Males have a higher risk of being diagnosed with ICU delirium (63% vs 36%) and being initiated on AAP (44% vs 40%) compared to females [ 4, 5].
In this retrospective investigation, we hypothesized that male gender was more likely to be associated with hyperactive symptoms of ICU delirium, and that males were more likely to be discharged on AAP after an ICU stay. After obtaining approval from the Institutional Review Board, we performed a retrospective analysis on patients admitted to the adult ICUs at the Penn State Health Milton S. Hershey Medical Center between January 2012 and December 2014. Charts were reviewed for the following inclusion criteria: age older than 18 years and AAP initiation in the ICU. Patients were excluded if they were on AAP prior to ICU admission. Documentation was analyzed for symptoms associated with AAP initiation based on the previously described Intensive Care Delirium Checklist Worksheet (ICDSC), pre-existing psychiatric diagnoses, and ICU type. Analyses were performed using SAS (v. 9.4; SAS, NC, USA) and significance was set at p < 0.05.
Of 12,984 patients admitted between 2012 and 2014, 346 (2.6%) patients were newly initiated on an AAP during their ICU stay, and 32 (8.6%) patients expired prior to discharge. In total, 346 patients and 314 patients were analyzed for initial and discharge-related variables, respectively (Table  1). No gender differences were observed in the concurrent psychiatric diagnoses of major depression ( p = 0.13), bipolar disorder ( p = 0.54), or schizophrenia ( p = 0.99). However, males had a higher length of ICU stay compared to females ( p = 0.002) but not total hospital stay ( p = 0.07). As previously observed, males had higher rates of initiation of AAP ( p = 0.0001) and continuation after discharge ( p = 0.034). We demonstrated that males were more likely to have documentation of agitation ( p = 0.032), hallucinations ( p = 0.018), impulsiveness ( p = 0.033), and combativeness ( p = 0.001) compared to females. No differences were found in documentation of restlessness ( p = 0.251), confusion ( p = 0.60), insomnia ( p = 0.70), lethargy ( p = 0.34), or depressed affect ( p = 0.62).
Table 1
Demographics and clinical characteristics of ICU patients initiated on AAP for delirium ( N = 346)
Characteristic
Male
( n = 230)
Female
( n = 116)
p value*
Age (years), mean (± SD)
60.1 (± 19.3)
58.4 (± 21.0)
0.459
Psychiatric diagnoses, n
 Major depression
82
51
0.133
 Bipolar depression
18
7
0.543
 Schizophrenia
6
3
0.990
Delirium manifestations b
 Hyperactive symptoms, n
  Agitation
213
99
0.032*
  Hallucination
159
94
0.018*
  Combativeness
139
90
0.001*
  Impulsiveness
121
75
0.033*
  Restlessness
58
36
0.251
 Hypoactive symptoms, n
  Confusion
26
11
0.605
  Insomnia/altered sleep
169
83
0.704
  Lethargy
56
23
0.344
  Depressed affect
35
20
0.627
ICU subtype, n (%)
 Medical
53 (23)
36 (31)
0.201
 Surgical c
177 (77)
80 (69)
 
Length of stay (days), median (IQR)
 ICU
11.0 (1–21)
8 (1–15)
0.002*
 Hospital
18 (0.25–35.75)
16 (0.75–31.25)
0.070
Discharge disposition, n (%)
 Home
37 (16)
37 (18.1)
0.548
 Expired
24 (10.4)
8 (6.8)
 
 Long-term care facility
163 (72.6)
86 (74.1)
 
Continuation of AAP on discharge, n (%)
123 (70.7)
51 (29.3)
0.034*
AAP atypical antipsychotic medications, ICU intensive care unit, IQR interquartile range, SD standard deviation
a p values from two-sample t test (mean), chi-square test ( n), or Mann–Whitney test (median and interquartile range)
b p value from chi-square test, χ 2 critical value = 3.841, df = 1, α = 0.05
cAggregated from neurosurgical, surgical, trauma, and cardiothoracic ICU populations. Medical implies all others
*Significant at p < 0.05
Prior studies have demonstrated higher rates of AAP initiation and continuation in male ICU patients. To our knowledge, our investigation is the first to show an association between male gender symptoms of hyperactive delirium and initiation of AAP in the ICU. As hyperactive symptoms are more visible and more likely to invoke safety concerns, we suspect that this leads to a higher rate of initiation and continuation of AAP in male patients. Thus, hyperactive symptoms drive the gender differences observed in AAP administration in the ICU. Further research is required to substantiate these findings and assess their clinical implications.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

This study was approved by the Penn State College of Medicine IRB (STUDY00000628).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://​creativecommons.​org/​publicdomain/​zero/​1.​0/​) applies to the data made available in this article, unless otherwise stated.
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