Antipsychotics for management of delirium – A systematic review

The existing research on antipsychotics for the treatment of delirium was reviewed. Our systematic review and meta-analysis showed that antipsychotics are not associated with a significant change in duration of delirium, mortality rate or occurrence of adverse events.

Research Results

Findings: It was found that antipsychotic treatment did not affect duration of delirium, mortality rate, or incidence of adverse events. Treatment with an antipsychotic was associated with a shorter duration of hospital length of stay (i.e. antipsychotic favoured), yet intensive care unit length of stay was found to be shorter with a non-antipsychotic intervention (i.e. control group favoured). The current evidence is poor and insufficient to draw conclusions about the effect of antipsychotic medication on the duration and severity of delirium. These results should be interpreted with caution, as additional studies of improved design must be conducted before the lack of effect of antipsychotics on the aforementioned outcomes can be confirmed.

About the Project

At times it may be necessary to prescribe medications to treat distressing behavioral disturbances. It is suggested by clinical guidelines and experts that antipsychotics be reserved to manage delirium-associated behavioral disturbances are severe or distressing when non-drug methods fail.

Up to 75% of patients treated for delirium are prescribed antipsychotics, depending on the type of patient and severity of symptoms. Antipsychotics, however, may have significant side effects, particularly in the elderly, including the potential to worsen delirium and increased risk of sudden death.

The efficacy and safety of antipsychotics for delirium has not been clearly delineated, therefore we will conduct a systematic review through The Cochrane Collaboration to determine the efficacy and safety of antipsychotics for the treatment of delirium in hospitalized patients.

Project Team

Principal Investigator:

Lisa Burry, BScPharm, PharmD — Mount Sinai Hospital

Co-Investigators:

Chaim Bell, MD, FRCPC, PhD — Mount Sinai Hospital

Wesley Ely, MD — Vanderbilt University

Dean Fergusson, PhD, MHA — Ottawa Hospital Research Institute

Jay Luxenberg, MD — University of California San Francisco

Sangeeta Mehta, MD, BSc, FRCP(C) — Mount Sinai Hospital

Marc Perreault, PharmD, BCPS — Université de Montréal/McGill University Health Centre

Louise Rose, RN, BN, MN, PhD — University of Toronto

Knowledge Users and Partners:

Neill Adhikari, MDCM, MSc — Sunnybrook Health Sciences Centre

Ingrid Egerod, RN, PhD — University of Copenhagen

José Morais, MD — Canadian Geriatrics Society

Doug Sellinger, BSP, MALT — Canadian Society of Hospital Pharmacists

Samir Sinha, MD, DPhil, FRCPC — Mount Sinai Hospital

Lesley Wiesenfeld, MD, FRCPC — Mount Sinai Hospital

Camilla Wong, MD, MHSc, FRCPC — St. Michael’s Hospital

Project Contact: Lisa Burry — lisa.burry@sinaihealthsystem.ca

KS 2013-10

Key Findings for Researchers

Key Findings for Researchers

The results of this study identified a gap in the literature around the use of antipsychotic medication for the management of delirium. These findings should guide future research in this area.

  • The current evidence is poor and insufficient to draw conclusions about the effect of antipsychotic medication on the duration and severity of delirium

Why This Study was Needed

Antipsychotics are routinely used to treat patients with delirium, however the use of antipsychotics has been suggested to be associate with an increased risk of adverse events, including sudden cardiac arrest in elderly patients.

How This Study Addresses the Gap

A systematic review was undertaken to examine the efficacy of antipsychotic medications for the treatment of hospitalized, acutely ill patients compared to alternative treatments or placebo on the management of delirium. Seven of the largest medical databases were searched (MEDLINE, Embase, CINAHL, Cochrane Database of Clinical Controlled Trials and ERIC) using search terms related to antipsychotic medication and delirium. Over 20,000 references were identified of which only five articles were included in the review. The main reason studies were excluded was they used another antipsychotic medication as a comparator or they did not report on the outcome variables of interest. Overall, the quality of evidence was very poor.

Future Research

Additional, high quality studies are needed to determine the effect of antipsychotic use on acutely ill patients with delirium, and inform clinical practice.

Rationale, Objective & Research Plan

Rationale: Antipsychotics may have significant side effects, particularly in the elderly, including the potential to worsen delirium and increase risk of sudden death. The efficacy and safety of antipsychotics for delirium had not been clearly delineated.

Objective: A systematic review was undertaken to examine the efficacy of antipsychotic medications for the treatment of hospitalized, acutely ill patients compared to alternative treatments or placebo on the management of delirium.

Research Plan: Seven of the largest medical databases were searched (MEDLINE, Embase, CINAHL, Cochrane Database of Clinical Controlled Trials, and ERIC) using search terms related to antipsychotic medication and delirium. Over 20,000 references were identified of which only five articles were included in the review. The main reason studies were excluded was they used another antipsychotic medication as a comparator or they did not report on the outcome variables of interest. Overall, the quality of evidence was very poor.