Frequency and Outcome of Neuroleptic Rotation in the Management of Delirium in Patients with Advanced Cancer

Abstract

PurposeThe response to haloperidol as a first-line neuroleptic and the pattern of neuroleptic rotation after haloperidol failure have not been well defined in palliative care. The purpose of this study was to determine the efficacy of haloperidol as a first-line neuroleptic and the predictors associated with the need to rotate to a second neuroleptic.Materials and MethodsWe conducted a retrospective review of the charts of advanced cancer patients admitted to our acute palliative care unit between January 2012 and March 2013. Inclusion criteria were a diagnosis of delirium and first-line treatment with haloperidol.ResultsAmong 167 patients with delirium, 128 (77%) received only haloperidol and 39 (23%) received a second neuroleptic. Ninety-one patients (71%) who received haloperidol alone improved and were discharged alive. The median initial haloperidol dose was 5 mg (interquartile ranges [IQR], 3 to 7 mg) and the median duration was 5 days (IQR, 3 to 7 days). The median final haloperidol dose was 6 mg (IQR, 5 to 7 mg). A lack of treatment efficacy was the most common reason for neuroleptic rotation (87%). Significant factors associated with neuroleptic rotation were inpatient mortality (59% vs. 29%, p=0.001), and being Caucasian (87% vs. 62%, p=0.014). Chlorpromazine was administered to 37 patients (95%) who were not treated successfully by haloperidol. The median initial chlorpromazine dose was 150 mg (IQR, 100 to 150 mg) and the median duration was 3 days (IQR, 2 to 6 days). Thirteen patients (33%) showed reduced symptoms after the second neuroleptic.ConclusionNeuroleptic rotation from haloperidol was only required in 23% of patients with delirium and was associated with inpatient mortality and white race.

Clinical Assessment and Management of Delirium in the Palliative Care Setting

“…Small observational studies in cancer patients have compared haloperidol, risperidone, and olanzapine with aripiprazole ( n = 21, case-matched) [ 103 ] or with quetiapine ( n = 27) [ 104 ] with improvement in MDAS scores, but more EPS reported with haloperidol. In some countries, levomepromazine (methotrimeprazine) or chlorpromazine are used for symptomatic relief of agitated delirium due to their sedative effect [ 105 – 107 ].…”

Pharmacological and non-pharmacological treatment of delirium in an oncological hospital service: an integrative review

“…This integrative review found a sample of ten articles (16)(17)(18)(19)(20)(21)(22)(23)(24)(25) , which were in accordance to the inclusion criteria. All of them took place in hospitals, four of which were in the United States, three in Japan, one in Saudi Arabia, one in England, and one in Switzerland.…”

“…The data collection of the articles (16)(17)(18)(19)(20)(21)(22)(23)(24)(25) included in the integrative review was made possible by an instrument that contained: identification, characteristics of the study and evaluation of the methodological rigor (12) .…”

Acute symptomatic complications among patients with advanced cancer admitted to acute palliative care units: A prospective observational study

“…In contrast, the low rates of resolution for delirium were likely related to the pathophysiologic changes in the last days of life. 33,34 There is currently a paucity of clinical trials in delirium among cancer patients. 35 Further research is urgently needed to optimize delirium management in APCU patients.…”