A Unified Primary Care Approach for the Management of Insomnia and Confusion Using the Clinical Pathway

Abstract

Background Delirium -characterized by an acute or subacute decline in cognitive functioning- and confusion are risk factors for falls and its related injuries. Therefore, we designed a unified clinical pathway to reduce the risk of delirium among hospitalized patients. Methods A unified approach of pharmacotherapy for managing insomnia and confusion, which is subdivided based on the patients’ age (<70 versus ≧70 years) and presence of diabetes mellitus, was implemented in Nagoya Memorial Hospital, Japan. Risk factors for delirium were assessed via a multidisciplinary approach. For older high-risk patients, suvorexant or trazodone was prophylactically prescribed to promote sleep. If delirium occurred, either quetiapine or perospirone was administered prior to the usage of risperidone or haloperidol. The amounts of prescribed sleep inducers and antipsychotic agents were examined. The application rate of the clinical pathway and incidence of falls were compared before and after its introduction. Results The application of a unified approach significantly decreased the prescribed amounts of benzodiazepines and may be associated with the reduced incidence of falls among inpatients. Conclusions A clinical pathway assisted the selection of sleep inducers and antipsychotic agents. This is useful for managing elderly patients safely by preventing delirium and subsequent falls.