Antipsychotic prescribing patterns during and after critical illness: a prospective cohort study

Abstract

BackgroundAntipsychotics are used to treat delirium in the intensive care unit (ICU) despite unproven efficacy. We hypothesized that atypical antipsychotic treatment in the ICU is a risk factor for antipsychotic prescription at discharge, a practice that might increase risk since long-term use is associated with increased mortality.MethodsAfter excluding patients on antipsychotics prior to admission, we examined antipsychotic use in a prospective cohort of ICU patients with acute respiratory failure and/or shock. We collected data on medication use from medical records and assessed patients for delirium using the Confusion Assessment Method for the ICU. Using multivariable logistic regression, we analyzed whether age, delirium duration, atypical antipsychotic use, and discharge disposition (each selected a priori) were independent risk factors for discharge on an antipsychotic. We also examined admission Acute Physiology and Chronic Health Evaluation (APACHE) II score, haloperidol use, and days of benzodiazepine use in post hoc analyses.ResultsAfter excluding 18 patients due to prior antipsychotic use and three who withdrew, we included 500 patients. Among 208 (42%) treated with an antipsychotic, median (interquartile range) age was 59 (49–69) years and APACHE II score was 26 (22–32), characteristics that were similar among antipsychotic nonusers. Antipsychotic users were more likely than nonusers to have had delirium (93% vs. 61%, p < 0.001). Of the 208 antipsychotic users, 172 survived to hospital discharge, and 42 (24%) of these were prescribed an antipsychotic at discharge. Treatment with an atypical antipsychotic was the only independent risk factor for antipsychotic prescription at discharge (odds ratio 17.6, 95% confidence interval 4.9 to 63.3; p < 0.001). Neither age, delirium duration, nor discharge disposition were risk factors (p = 0.11, 0.38, and 0.12, respectively) in the primary regression model, and post hoc analyses found APACHE II (p = 0.07), haloperidol use (p = 0.16), and days of benzodiazepine use (p = 0.31) were also not risk factors for discharge on an antipsychotic.ConclusionsIn this study, antipsychotics were used to treat nearly half of all antipsychotic-naïve ICU patients and were prescribed at discharge to 24% of antipsychotic-treated patients. Treatment with an atypical antipsychotic greatly increased the odds of discharge with an antipsychotic prescription, a practice that should be examined carefully during medication reconciliation since these drugs carry “black box warnings” regarding long-term use.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

“…A false-positive screening, although rare with either the CAM-ICU or the ICDSC, may result in unnecessary pharmacologic or nonpharmacologic treatment. ICU antipsychotic use is often associated with its continuation and prolonged administration after ICU and hospital discharge (305)(306)(307). Delirium screening may be burdensome for nursing staff (287).…”

“…Although this recommendation discourages the "routine" use of antipsychotic agents in the treatment of delirium, patients who experience significant distress secondary to symptoms of a delirium such as anxiety, fearfulness, hallucinations, or delusions, or who are agitated and may be physically harmful to themselves or others, may benefit from short-term use of haloperidol or an atypical antipsychotic until these distressing symptoms resolve based on the panel's clinical experience. Patients who start with an antipsychotic for delirium in the ICU often remain on these medications unnecessarily after discharge (305)(306)(307). Continued exposure to antipsychotic medication can result in significant morbidity and financial cost.…”

<p>Use of Atypical Antipsychotics in Long-Term Care Residents with Parkinson’s Disease and Comorbid Depression</p>

“…Antipsychotics might be administrated for behavioral symptoms of dementia or for treating delirium in COPD when dementia or COPD coexist with PD. 24 These clinical conditions are not associated with dopaminergic medication use, thus, antipsychotics such as risperidone might be prescribed to treat behavioral symptoms of dementia or COPD. The use of inappropriate antipsychotics was higher in typical antipsychotics and antidepressant (SSRI/ SNRI) users and this might refer to the use of atypical antipsychotics for preexisting mental disorders.…”

Pharmacist‐driven discontinuation of antipsychotics for ICU delirium: A quasi‐experimental study

“…Chronic Health Evaluation II (APACHE II) scores, use of atypical antipsychotics, and total days treated with benzodiazepines were found as independent risk factors for discharge on antipsychotics. [23][24][25] Continuation of these agents at hospital discharge is concerning due to the harm associated with chronic use in the absence of any long term benefits derived when prescribed for ICU delirium. The use of antipsychotics, especially for prolonged periods of time, increases the risk for side effects including QTc prolongation, excess sedation, arrhythmias, extrapyramidal symptoms, and increased risk of death in older adults with dementia.…”