A 68-year-old woman presented with a sudden severe
headache,
vomiting, and disturbed consciousness. She was admitted to the emergency room. Computed tomography (CT) revealed a
hemorrhage in the right temporal lobe. Angiography demonstrated a
ruptured aneurysm in the right middle cerebral artery (MCA) and an unruptured
aneurysm in the left MCA. The
subarachnoid hemorrhage was grade 3 (Hunt and Kosnik classification). Emergency
craniotomy, clipping of the
ruptured aneurysm and removal of the
hematoma were performed. The left
hemiparesis improved, and the patient was able to walk. We prescribed
triazolam (0.25 mg/day) to treat the patient's
insomnia. The unruptured
aneurysm was additionally clipped on the 15th hospital day. After the second operation, the patient complained of
delirium with
restlessness, excitement, disorganized behavior, and sleep disturbance. Treatment with thiapride (150 mg/day) did not improve the
delirium. We additionally administered
Yi-gan san (7.5 g/day) and switched the
triazolam to
ramelteon (8 mg/day). The Memorial
Delirium Assessment Scale score improved dramatically (from 16 at onset to 5 on day 7 and 1 at two months).
Yi-gan san is reported to be effective for the treatment of behavioral and psychological symptoms of
dementia.
Ramelteon, a
melatonin receptor agonist, is implicated in the regulation of the sleep-wake cycle.
Ramelteon, unlike other
hypnotic drugs, does not cause oversedation,
rebound insomnia,
withdrawal symptoms or dependence. In addition, we have noted no adverse effects, including oversedation or clinically significant changes in laboratory data, during combination
therapy. A combination of
ramelteon and
Yi-gan san may therefore be beneficial in elderly patients with
delirium, especially when there is a risk of oversedation.