Clinician Article
Antipsychotics for Treating Delirium in Hospitalized Adults: A Systematic Review.
PMID: 31476770
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GeriatricsRelevance - 7/7
Newsworthiness - 6/7 -
Hospital Doctor/HospitalistsRelevance - 6/7
Newsworthiness - 5/7 -
Internal MedicineRelevance - 6/7
Newsworthiness - 5/7 -
NeurologyRelevance - 6/7
Newsworthiness - 5/7
Abstract
BACKGROUND: Delirium is common in hospitalized patients and is associated with worse outcomes. Antipsychotics are commonly used; however, the associated benefits and harms are unclear.
PURPOSE: To conduct a systematic review evaluating the benefits and harms of antipsychotics to treat delirium in adults.
DATA SOURCES: PubMed, Embase, CENTRAL, CINAHL, and PsycINFO from inception to July 2019 without language restrictions.
STUDY SELECTION: Randomized controlled trials (RCTs) of antipsychotic versus placebo or another antipsychotic, and prospective observational studies reporting harms.
DATA EXTRACTION: One reviewer extracted data and assessed strength of evidence (SOE) for critical outcomes, with confirmation by another reviewer. Risk of bias was assessed independently by 2 reviewers.
DATA SYNTHESIS: Across 16 RCTs and 10 observational studies of hospitalized adults, there was no difference in sedation status (low and moderate SOE), delirium duration, hospital length of stay (moderate SOE), or mortality between haloperidol and second-generation antipsychotics versus placebo. There was no difference in delirium severity (moderate SOE) and cognitive functioning (low SOE) for haloperidol versus second-generation antipsychotics, with insufficient or no evidence for antipsychotics versus placebo. For direct comparisons of different second-generation antipsychotics, there was no difference in mortality and insufficient or no evidence for multiple other outcomes. There was little evidence demonstrating neurologic harms associated with short-term use of antipsychotics for treating delirium in adult inpatients, but potentially harmful cardiac effects tended to occur more frequently.
LIMITATIONS: Heterogeneity was present in terms of dose and administration route of antipsychotics, outcomes, and measurement instruments. There was insufficient or no evidence regarding multiple clinically important outcomes.
CONCLUSION: Current evidence does not support routine use of haloperidol or second-generation antipsychotics to treat delirium in adult inpatients.
PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO: CRD42018109552).
Clinical Comments
Geriatrics
Most geriatricians know the pre-disposing and precipitating causes of delirium. In spite of best practice, delirium occurs. There are many things to do including evaluation for potentially correctable causes and employing established non-pharmacological modalities. The hardest thing to do in serious delirium is to avoid drug therapy. In my experience, drug-free treatment of moderate/severe delirium is rare. This article is very helpful to those who want to resist the pressures to prescribe or don't know that this was an evidence based alternative. It leaves open the question of whether medications are helpful in those patients at high risk of harm to self and others. In these situations, the anti-psychotics are used as sedative medications and are a better choice than benzodiazepines.
Geriatrics
This review provides significant clinical guidance for this very important medical issue. It highlights some of the concerns with AAP and provides new evidence.
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