In the Journals

Evidence does not support antipsychotics for prevention, treatment of delirium in hospitals

Haloperidol and second-generation antipsychotics should not be routinely used to prevent or treat delirium in hospitalized patients based on evidence evaluated in two systematic reviews published in the Annals of Internal Medicine.

Delirium is common following acute illness or surgery, particularly in older adults, and complications related to delirium cost the United States up to $38 billion each year, the authors noted.

“Beyond its economic impact, delirium is also associated with poor clinical outcomes, including physical and cognitive decline, as well as increased institutionalization and mortality,” Esther S. Oh, PhD, associate professor of medicine at Johns Hopkins University School of Medicine, and colleagues wrote.

To assess the effectiveness of antipsychotics in preventing delirium, Oh and colleagues evaluated 14 randomized control trials that comprised 4,281 patients.

Older adult looking confused 
Haloperidol and second-generation antipsychotics should not be routinely used to prevent or treat delirium in hospitalized patients based on evidence evaluated in two systematic reviews published in the Annals of Internal Medicine.
Source: Adobe Stock

Researchers found no differences in the incidence or duration of delirium, length of hospital stay or mortality between those given haloperidol and those given placebo. They also found little to no evidence that haloperidol affected cognitive function, delirium severity, inappropriate continuation of antipsychotics or sedative use.

Oh and colleagues found evidence that second-generation antipsychotics may lower the incidence of delirium in postoperative patients, but they noted that further research is needed to confirm the finding.

To assess the efficacy of antipsychotics in the treatment of delirium in hospitalized adults, Roozbeh Nikooie, MD, a research follow at Johns Hopkins University, and colleagues evaluated findings from 16 randomized control trials and 10 observational studies that included 5,607 patients.

Nikooie and colleagues found no difference in sedation status, duration of delirium, length of hospital stay or mortality among those who were give haloperidol, second-generation antipsychotics or placebo. For delirium severity and cognitive functioning, there were no differences between those who were given haloperidol and second-second generation antipsychotics, and there was insufficient or no evidence of differences between those given antipsychotics or placebo.

Potentially harmful cardiac events occurred more frequently in those given antipsychotics to treat or prevent delirium compared with those given placebo.

“With regard to use of antipsychotics for broad treatment of delirium, I believe the ndings presented are sufcient to stop this clinical practice,” Edward R. Marcantonio, MD, SM, section chief for research in the division of general medicine and primary care at Beth Israel Deaconess Medical Center, wrote in an editorial accompanying the study.

Marcantonio noted that future research should focus on determining subgroups of patients for which the benefits of antipsychotic treatment outweigh the harms, which treatments are the least harmful to those groups, and how the antipsychotics should be administered. – by Erin Michael

References:

Marcantonio ER. Ann Intern Med. 2019;doi:10.7326/M19-2624.

Nikooie R, et al. Ann Intern Med. 2019;doi:10.7326/M19-1860.

Oh ES, et al. Ann Intern Med. 2019;doi:10.7326/M19-1859.

Disclosures: Marcantonio and Oh report no relevant financial disclosures. Nikooie reports having a contract from the AHRQ during the conduct of the study. Please see studies for all other authors’ relevant financial disclosures.

Haloperidol and second-generation antipsychotics should not be routinely used to prevent or treat delirium in hospitalized patients based on evidence evaluated in two systematic reviews published in the Annals of Internal Medicine.

Delirium is common following acute illness or surgery, particularly in older adults, and complications related to delirium cost the United States up to $38 billion each year, the authors noted.

“Beyond its economic impact, delirium is also associated with poor clinical outcomes, including physical and cognitive decline, as well as increased institutionalization and mortality,” Esther S. Oh, PhD, associate professor of medicine at Johns Hopkins University School of Medicine, and colleagues wrote.

To assess the effectiveness of antipsychotics in preventing delirium, Oh and colleagues evaluated 14 randomized control trials that comprised 4,281 patients.

Older adult looking confused 
Haloperidol and second-generation antipsychotics should not be routinely used to prevent or treat delirium in hospitalized patients based on evidence evaluated in two systematic reviews published in the Annals of Internal Medicine.
Source: Adobe Stock

Researchers found no differences in the incidence or duration of delirium, length of hospital stay or mortality between those given haloperidol and those given placebo. They also found little to no evidence that haloperidol affected cognitive function, delirium severity, inappropriate continuation of antipsychotics or sedative use.

Oh and colleagues found evidence that second-generation antipsychotics may lower the incidence of delirium in postoperative patients, but they noted that further research is needed to confirm the finding.

To assess the efficacy of antipsychotics in the treatment of delirium in hospitalized adults, Roozbeh Nikooie, MD, a research follow at Johns Hopkins University, and colleagues evaluated findings from 16 randomized control trials and 10 observational studies that included 5,607 patients.

Nikooie and colleagues found no difference in sedation status, duration of delirium, length of hospital stay or mortality among those who were give haloperidol, second-generation antipsychotics or placebo. For delirium severity and cognitive functioning, there were no differences between those who were given haloperidol and second-second generation antipsychotics, and there was insufficient or no evidence of differences between those given antipsychotics or placebo.

Potentially harmful cardiac events occurred more frequently in those given antipsychotics to treat or prevent delirium compared with those given placebo.

“With regard to use of antipsychotics for broad treatment of delirium, I believe the ndings presented are sufcient to stop this clinical practice,” Edward R. Marcantonio, MD, SM, section chief for research in the division of general medicine and primary care at Beth Israel Deaconess Medical Center, wrote in an editorial accompanying the study.

Marcantonio noted that future research should focus on determining subgroups of patients for which the benefits of antipsychotic treatment outweigh the harms, which treatments are the least harmful to those groups, and how the antipsychotics should be administered. – by Erin Michael

References:

Marcantonio ER. Ann Intern Med. 2019;doi:10.7326/M19-2624.

Nikooie R, et al. Ann Intern Med. 2019;doi:10.7326/M19-1860.

Oh ES, et al. Ann Intern Med. 2019;doi:10.7326/M19-1859.

Disclosures: Marcantonio and Oh report no relevant financial disclosures. Nikooie reports having a contract from the AHRQ during the conduct of the study. Please see studies for all other authors’ relevant financial disclosures.