Takahashi Keitaro, Kiryu Kana, Harada Hiroyuki, Kato Tadafumi, Tamune Hidetaka
Department of Psychiatry and Behavioral Science, Juntendo University Graduate School of Medicine, Tokyo, JPN.
Cureus. 2025 Jun 2;17(6):e85232. doi: 10.7759/cureus.85232. eCollection 2025 Jun.
Subsyndromal delirium (SSD), characterized by subthreshold symptoms of delirium such as disturbances in attention and cognition, is prevalent in the intensive care unit (ICU) and is associated with prolonged hospitalization and delayed functional recovery. However, evidence-based treatment guidelines remain limited. Here, we present a postoperative patient with SSD successfully managed with daridorexant and quetiapine. A 76-year-old man with a history of pharyngeal cancer and tracheostomy developed acute insomnia in the ICU following surgery for esophageal cancer. Lemborexant was initiated on postoperative day (POD) 6 and titrated to the maximum dose of 10 mg on POD 8, but it caused morning drowsiness that interfered with participation in rehabilitation. On POD 10, he was referred to the Consultation-Liaison team. Based on his disrupted sleep-wake cycle and fluctuating mood following dyspnea due to aspiration pneumonia, he was diagnosed with SSD (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)) with comorbid acute insomnia. We initiated daridorexant on POD 10 and increased the dose to 50 mg on POD 12, leading to reduced morning drowsiness and improved sleep initiation. Although these symptoms improved, fluctuating mood and poor appetite persisted slightly. Low-dose quetiapine (12.5 mg) was subsequently added, resulting in stabilization of psychiatric symptoms and steady rehabilitation progress. He was discharged on POD 31, and all psychotropic medications were successfully discontinued at discharge. Conclusions: Daridorexant, a dual orexin receptor antagonist (DORA) with a shorter half-life, appeared effective in reducing morning drowsiness. As the use of short-acting benzodiazepines has a potential risk of inducing delirium, the combination of daridorexant and low-dose quetiapine may present a therapeutic option for managing SSD with delayed awakening in the postoperative setting.
亚综合征谵妄（SSD）以谵妄的阈下症状为特征，如注意力和认知障碍，在重症监护病房（ICU）中很常见，并且与住院时间延长和功能恢复延迟有关。然而，基于证据的治疗指南仍然有限。在此，我们报告一例术后SSD患者，使用达立多雷克斯和喹硫平成功治疗。一名76岁男性，有咽癌和气管切开术病史，食管癌手术后在ICU出现急性失眠。术后第6天开始使用伦博雷克斯，术后第8天滴定至最大剂量10mg，但出现晨间嗜睡，影响康复参与。术后第10天，他被转诊至会诊-联络团队。基于他因吸入性肺炎导致呼吸困难后睡眠-觉醒周期紊乱和情绪波动，他被诊断为患有合并急性失眠的SSD（《精神疾病诊断与统计手册》第五版，修订版（DSM-5-TR））。我们在术后第10天开始使用达立多雷克斯，术后第12天剂量增加至50mg，晨间嗜睡减轻，入睡情况改善。尽管这些症状有所改善，但情绪波动和食欲不佳仍略有持续。随后添加低剂量喹硫平（12.5mg），精神症状稳定，康复进展顺利。他于术后第31天出院，出院时所有精神药物均成功停用。结论：达立多雷克斯是一种半衰期较短的双重食欲素受体拮抗剂（DORA），似乎对减轻晨间嗜睡有效。由于使用短效苯二氮䓬类药物有诱发谵妄的潜在风险，达立多雷克斯和低剂量喹硫平联合使用可能为术后延迟觉醒的SSD管理提供一种治疗选择。
