Written by Clay Smith
Neither haloperidol nor second generation antipsychotics were effective in improving patient-centered outcomes in hospitalized adults with delirium.
Why does this matter?
Delirium is common: 20% of general inpatients and nearly 80% of ICU patients on a ventilator. It’s also associated with worse outcomes. Once delirium sets in, what is the best way to treat it? We often reach for antipsychotics, either haloperidol or second generation antipsychotic drugs (2GA), but do these help?
Talk about the good ole days…
This was a systematic review of 16 RCTs and 10 prospective observational studies, 5,607 patients, on use of haloperidol or 2GAs on treatment of acute delirium in hospitalized adults. When comparing haloperidol and 2GAs vs placebo, there was no difference in, “sedation status (low and moderate SOE [strength of evidence]), delirium duration, hospital length of stay (moderate SOE), or mortality.” There also did not appear to be a difference in delirium severity or cognitive functioning when haloperidol and 2GAs were compared head to head. There did not appear to be neurological harms with antipsychotics (i.e. extrapyramidal side effects), but prolongation of the QTc was a potential harmful effect, especially among 2GAs. This review concluded that antipsychotics were ineffective in the treatment of acute delirium in these patients. So, what are we supposed to do? We know benzodiazepines make delirium worse. In clinical practice, pharmacologic agents are sometimes needed but should be a last resort. Non-pharmacologic methods, such as, “reminiscing, interacting with family and friends, sleep enhancement, and early mobilization,” are preferred.
A companion study was also released in the same issue on the prevention of delirium.
Antipsychotics for Treating Delirium in Hospitalized Adults: A Systematic Review. Ann Intern Med. 2019 Sep 3. doi: 10.7326/M19-1860. [Epub ahead of print]
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Reviewed by Thomas Davis