Delirium – The basic benefits and risk of antipsychotics
Antipsychotic use should be reserved only for severe agitation who:
- Risk interruption of essential medical treatment (self extubating, etc.)
- Self injury or injury to others
- Experience severe, distressing psychotic symptoms (hallucinations, delusions, etc.)
Antipsychotics DO NOT resolve delirium
- A large ICU randomized control trial showed no difference in delirium free days in haloperidol vs ziprasidone
- 2019 systematic review showed no difference in delirium duration, hospital length of stay, or mortality (and sedation) between haloperidol vs second-generation antipsychotics vs placebo for delirium treatment
Antipsychotics DO NOT prevent delirium
2019 systematic review showed no difference in delirium incidence or duration, hospital length of stay, and mortality between haloperidol and placebo for delirium prevention
- There was limited evidence that second-generation antipsychotics may lower the incidence of delirium in post-operative patients, but more research is needed
Antipsychotics are associated with real harms
- In older patients with dementia, antipsychotics are associated higher mortality (~ 1.7x over 10 weeks; cardiovascular events, infections), though this has not been established in patients with delirium.
- With short term use, the risk is likely much lower but still being debated.
- The use of antipsychotics in delirium may cause sedation, switching from hyper- to hypoactive delirium, and prolong delirium.
PEARL: Antipsychotics do not prevent/resolve delirium; they only treat hyperactive symptoms.