Antipsychotics for treatment of delirium in hospitalised non-ICU patients

Abstract

Background Guidelines suggest limited and cautious use of antipsychotics for treatment of delirium where nonpharmacological interventions have failed and symptoms remain distressing or dangerous, or both. It is unclear how well these recommendations are supported by current evidence. Objectives Our primary objective was to assess the efficacy of antipsychotics versus nonantipsychotics or placebo on the duration of delirium in hospitalised adults. Our secondary objectives were to compare the efficacy of: 1) antipsychotics versus nonantipsychotics or placebo on delirium severity and resolution, mortality, hospital length of stay, discharge disposition, health-related quality of life, and adverse effects; and 2) atypical vs. typical antipsychotics for reducing delirium duration, severity, and resolution, hospital mortality and length of stay, discharge disposition, health-related quality of life, and adverse effects. Search methods We searched MEDLINE, Embase, Cochrane EBM Reviews, CINAHL, Thomson Reuters Web of Science and the Latin American and Caribbean Health Sciences Literature (LILACS) from their respective inception dates until July 2017. We also searched the Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database, Web of Science ISI Proceedings, and other grey literature. Selection criteria We included randomised and quasi-randomised trials comparing 1) antipsychotics to nonantipsychotics or placebo and 2) typical to atypical antipsychotics for the treatment of delirium in adult hospitalised (but not critically ill) patients. 1 Antipsychotics for treatment of delirium in hospitalised non-ICU patients (Review)

Anti‐psychotics for treatment of delirium in hospitalized non‐ICU patients: A Cochrane Review Summary

“…Should a decision be made to initiate a pharmacological intervention, the NICE guidelines () stipulate first and second generation antipsychotics should be used for severe agitation and then only for a short period of time. The new data analysis (Burry et al, ) concurs with the NICE guidelines and the Australian clinical practice guidelines (Tropea et al, ); the data showed limited therapeutic benefit; therefore, pharmacological interventions should be introduced with great caution to avoid iatrogenic effects, and only if all other nonpharmacological options fail.…”

“…Clinical decision‐making is best aided by accessing clinical guidelines that are in alignment with global understanding around assessment and management of delirium. NICE () and the Australian guidelines for delirium management (Tropea et al, ) are excellent, up‐to‐date, and aligned with international research, and the Burry et al () review concur with their findings, to ensure the safest delivery of care at present‐day.…”

“…How long a person has had delirium is often difficult to discern because clinicians are often challenged to identify when the delirium commenced. Delirium onset is an important point, as are predisposing factors to which the patient may be at risk.A central recommendation, in alignment with Burry et al (2018), is that nurses should assess patients' underlying risks and what predisposing factors a patient may be exposed to. A primary aim is therefore to prevent delirium occurring in the first instance.…”

Olanzapine Versus Haloperidol for Treatment of Delirium in Patients with Advanced Cancer: A Phase III Randomized Clinical Trial

“…New guidelines recommend that the use of pharmacological interventions in the management of delirium should be limited to patients with distressing symptoms (such as agitation, anxiety, or perceptual disturbances) or if there are safety concerns in which the patient is a potential risk to themselves or others . In general, haloperidol, a typical or first‐generation antipsychotic, is recommended as the first line pharmacological option .…”

“…Recently, a Cochrane systematic review included nine trials with 727 participants, assessing antipsychotics for delirium treatment in non‐ICU patients . Seven trials included a comparison of a typical to an atypical antipsychotic drug or placebo, including three studies evaluating patients with advanced cancer .…”