Guanfacine for the management of the behavioral manifestations of delirium in older hospitalized adults.

INTRODUCTION

Delirium affects nearly half of hospitalized older adults and is associated with prolonged hospitalization, dementia, and death. The behavioral manifestations of delirium are generally managed with antipsychotics, but there is growing interest in alternative medical therapy, including guanfacine.

METHODS

This retrospective cohort study included patients ≥65 years of age admitted to Maine Medical Center between January 2021 and April 2023 and treated with guanfacine for delirium management on a non-ICU unit. Effectiveness outcomes included antipsychotic use and dose as well as a change in positive delirium screen after guanfacine initiation. Safety outcomes included incidence of hypotension, bradycardia, or transfer to ICU.

RESULTS

A total of 56 patients who received at least 1 dose of guanfacine were evaluated, and 38 patients (68%) with complete data for days -1 to +2 were included in the effectiveness analysis. Before guanfacine initiation, 22/38 patients (58%) were receiving an antipsychotic medication, compared with 18/38 (47%) after guanfacine initiation ( = 0.86). Patients received a median (interquartile range) 6.4 (3.3 to 16) olanzapine equivalents (OE) before guanfacine was initiated and 4.2 (1.7 to 10.0) OE after guanfacine (absolute difference 2.2 OE; relative difference, 34 %; = 0.8). All 56 patients were included in the safety analysis; 21 (38%) experienced hypotension, and of these, 7 (33%) patients required intervention. Twenty-three (41%) experienced bradycardia while on guanfacine, resulting in 1 patient being transferred to the ICU.

DISCUSSION

Upon initiation of guanfacine, patients with delirium had a reduction in daily antipsychotic exposure and a decrease in positive delirium screens. However, guanfacine was associated with hypotension and bradycardia.