Inpatient delirium: evidence refutes benefit of antipsychotics

  • Nikooie R & al.
  • Ann Intern Med
  • 3 Sep 2019

  • International Clinical Digest
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Takeaway

  • Haloperidol (Haldol) and second-generation antipsychotics do not improve outcomes when routinely used for delirium prevention or treatment among hospitalized adults.

Why this matters

  • Delirium is prevalent in this patient population, and antipsychotics are commonly used in its management.

Key results

  • For delirium prevention, compared with placebo, haloperidol and second-generation antipsychotics did not significantly improve:
    • Hospital length of stay.
    • Mortality.
  • Incident delirium:
    • Haloperidol did not reduce risk among mixed patient populations.
    • Second-generation antipsychotics reduced risk after on-pump cardiac or joint-replacement surgery (pooled relative risk, 0.36; 95% CI, 0.26-0.50).
  • Evidence was insufficient to assess effect on delirium severity, cognitive functioning.
  • For delirium treatment, compared with placebo, haloperidol and second-generation antipsychotics did not significantly improve:
    • Hospital length of stay.
    • Delirium duration.
    • Mortality.
  • Evidence was insufficient or conflicting regarding effect on delirium severity, cognitive functioning.

Expert comment

  • In an editorial, Edward R. Marcantonio, MD, SM, writes, “With regard to use of antipsychotics for broad treatment of delirium, I believe the findings presented are sufficient to stop this clinical practice. Future research should focus on defining patient subgroups and settings (if any) in which the benefits of antipsychotics outweigh harms … .”

Study design

  • Systematic reviews of antipsychotic therapy among hospitalized adults:
    • Delirium prevention: 14 randomized controlled trials among 4281 patients.
    • Delirium treatment: 26 randomized controlled trials and observational studies among 5607 patients.
  • Main outcomes: delirium measures, hospital stay, adverse events.
  • Funding: Agency for Healthcare Research and Quality.

Limitations

  • Heterogeneity in antipsychotic dosing, route of administration, outcome assessment, adverse event assessment.
  • Lack of/insufficient data for many outcomes.

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