Mount Sinai Med-Lit Review
Clinical question: Do acetylcholinesterase inhibitors help reduce the occurrence and severity of delirium in hospitalized patients?
Background: Delirium is a frequent complication in hospitalized patients and is associated with significant morbidity and mortality. Acetylcholinesterase inhibitors (AChEIs) have been proposed as potential agents to reduce the occurrence and severity of delirium. This study aimed to evaluate the efficacy of AChEIs for both prophylaxis and treatment of delirium in hospitalized patients.
Study design: Systematic review and meta-analysis
Synopsis: This study used PubMed, Embase, and Web of Science to ultimately find 10 randomized controlled trials (731 patients; mean age, 74 years; mean baseline Mini-Mental State Examination score, 23.9) focusing on delirium prevention and treatment. Eight trials examined prophylactic use in surgical patients, and two addressed established delirium. AChEIs significantly reduced the incidence of delirium (risk ratio, 0.68; 95% confidence interval [CI], 0.47 to 0.98; P=0.039), with the strongest evidence for prophylactic rivastigmine via transdermal patch. However, they did not significantly affect delirium duration, severity, or length of stay. Additionally, there were no significant differences in adverse events found when compared with placebo.
Limitations include the predominance of prophylaxis-focused trials and surgical patients, heterogeneity in drug selection, dosing, and administration routes, and the use of different scoring systems to assess delirium severity. Overall, these findings suggest AChEIs may help prevent delirium in high-risk surgical patients but offer limited benefit for established delirium.
Bottom line: AChEIs can reduce delirium when used prophylactically in surgical patients, but their role in reducing delirium severity, duration, or length of stay remains uncertain.
Citation: Pipek LZ, et al. Acetylcholinesterase inhibitors for delirium prevention: a systematic review and meta-analysis. Crit Care Med. 2025;53(10):e2054-e2061. doi: 10.1097/CCM.0000000000006786.
View Dr. Rasouli’s video review.
Dr. Rasouli
Dr. Rasouli is a hospitalist in the department of hospital medicine at Mount Sinai Hospital and an assistant professor of medicine at the Icahn School of Medicine at Mount Sinai, both in New York.