Ramelteon and Citicoline for Delirium

This will be a 5-day, non-randomized, open-label, consecutive case series of ramelteon treatment followed by a separate consecutive case series of citicoline treatment, both running in parallel with a non-randomized, observation-only, treatment as usual arm in hospitalized patients with delirium.

On the drug treatment arm, first five consecutive subjects meeting Diagnostic and Statistical Manual (DSM)-5 criteria for delirium will be given ramelteon 8 mg daily at bedtime for 5 days. The next five consecutive patients will be given citicoline 250 mg daily at bedtime for 2 days, followed by 500 mg daily at bedtime for 3 days. Patients on the observation-only arm will be screened and followed similarly, except they will not be given any experimental drugs. All subjects will continue to receive standard medical care for delirium, including optimal medical treatment, psychotropic medications and consultations with specialty services as necessary.

The study is a small pilot to see if there is good feasibility, tolerability and a signal for delirium improvement efficacy with the two medications. The goal is to develop the ability to conduct delirium research at this institution and obtain some preliminary pilot data. These data will be used to design and obtain funding for future, larger research studies. the data from each medication will be examined to look for patterns suggesting that one may be preferable for further research. However, given the very small sample size, meaningful between-group statistical analyses are not possible.

• Ramelteon (Drug), also known as Rozerem
• Citicoline (Drug)

Primary outcomes

• Number diagnosed and treated [End of study (anticipated 12 months from beginning of study)]: Number of subjects in each arm that are diagnosed with delirium and treated according to protocol. This is a feasibility measure, the investigators are measuring whether it is possible to screen, enroll, diagnose, treat and monitor a sufficient number of subjects with delirium at the study site.

Secondary outcomes

• Frequency of serious, less serious, and minor adverse events as measured by a clinical interview aided by an adverse event checklist [Daily for 5 days]
• Delirium prevalence [Baseline (Day 0)]: Number of subjects diagnosed with delirium according to Diagnostic and Statistical Manual (DSM)-5 criteria

Other outcomes

• Delirium severity [Daily for 5 days]: Score on Delirium Rating Scale-Revised (DRS-R98)
• Delirium duration [Daily for 5 days]: Number of days a subject continues to fulfill criteria for DSM-5 delirium diagnosis
• Length of hospital stay [through study completion, an average of 1 year]: Measured in days

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Admitted to inpatient units commonly known as 12-South or 12-North at Clements University Hospital
* Has capacity to give informed consent OR legally authorized representative is available at bedside
* Expected duration of hospitalization longer than 48 hours
* Fluent in English
* Can be screened by study physician within 24 hours of admission

Exclusion Criteria:

* History of angioedema or any other allergic reaction with previous ramelteon therapy
* Pregnant or currently breast-feeding
* Concurrent use of fluvoxamine
* Severe hepatic impairment
* Severe obstructive sleep apnea

• E. Sherwood Brown, MD, PhD, Principal investigator, University of Texas Southwestern Medical Center