Do antipsychotic drugs have a role in the modern management of delirium?
Dr Henry J. Woodford works as a consultant geriatrician for Northumbria Healthcare in northeast England. He originally trained at King's College London. His role at work includes acute frailty assessment and care on a delirium unit. He tweets @woodford_henry
Antipsychotic drugs are recommended for the management of distress caused by delirium when it is unresponsive to other de-escalation techniques. This class of medication is known to have many potential adverse effects, especially in older people with background cognitive impairment, i.e. the group most prone to developing delirium. These include falls, confusion, extra-pyramidal disorders, stroke and death.
The logic of prescribing these drugs is based on the assumption that because schizophrenia (which we don’t understand) can be stabilised by them, and it shares some features with delirium (which we also don’t understand), namely hallucinations and delusions, then they may also help delirious people. Given the potential to harm, we should question if there is any evidence that these drugs are beneficial. We should also go beyond this basic question and ask whether the use of these drugs blends well with our philosophy of best care.
Are antipsychotic drugs beneficial for people with delirium?
A meta-analysis published in 2016 identified 19 RCTs comparing antipsychotics to placebo for delirium: seven studies for prevention and 12 for symptom control. The conclusion was that antipsychotics did not reduce the incidence of delirium or improve severity, duration, length of hospital stay or mortality.
Since this review there have been further studies. In older people admitted to hospital and judged to be at risk of delirium (n = 242, mean age 83) antipsychotic use had no benefit for delirium incidence, severity, duration or mortality. In a palliative care setting (n = 247, mean age 75), antipsychotic use was associated with more severe delirium and increased mortality. Two studies (see study 1 and study 2) in ITU settings (n = 68, mean age 61; n = 1789, mean age 67) have shown that haloperidol didn’t reduce delirium incidence or improve 28-day survival.
So, despite thousands of people enrolled in RCTs, the combined conclusion is ‘no benefit’. This should not be a surprise. Standard management of delirium should include reducing anticholinergic drugs.2 Antipsychotic drugs are anticholinergic drugs. They may worsen confusion, increase the risk of falls or merely convert hyperactive to hypoactive forms. In the latter case we might make the person ‘easier to manage’ but increase their risk of other morbidities such as pneumonia and pressure ulcers.
Yet some will be tempted to argue that evidence-based medicine is flawed. It cannot predict the future for the person in front of you. Perhaps suggest more studies are needed or that exceptions exist. However, let’s take a step back, what are we actually trying to achieve?
Does antipsychotic use fit with our philosophy of best care?
What does excellent care for people with delirium look like? There is huge overlap between delirium and dementia and the approach to behavioural disturbance for both should be similar. The essence of care should be person-centred.
One example of this approach is the VIPS frame work: Value the person, treat as an Individual, see things from their Perspective and provide an enriched Social environment. We need to see behavioural disturbance as an expression of an unmet meet and develop a care culture that promotes enablement. We cannot ignore unmet needs in favour of a chemical restraint. Antipsychotic drugs are used in acute hospitals to make people easier to manage - to treat the system, not the individual. This is the polar opposite of being person-centred – ignoring individual needs and actively disabling. Therefore the two approaches cannot be used together as part of a coherent strategy.
Antipsychotic drugs can never add value, and only undermine our philosophy. Good delirium care has a lower rate of antipsychotic drug use; excellent care never uses them.