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Antipsychotics, benzodiazepines should not be used to treat delirium

ORLANDO, Fla. – Despite their frequent off-label use in hospitals, antipsychotics and benzodiazepines do not treat delirium in older patients, even in palliative care, according to a presenter at Hospital Medicine 2018.

Melissa L.P. Mattison, MD, chief of hospital medicine at Massachusetts General Hospital and associate professor of medicine at Harvard Medical School, also discussed transitioning care, mobility and polypharmacy in the geriatric population, as well as a new geriatric syndrome.

Antipsychotics and benzodiazepines

Mattison emphasized that antipsychotics and benzodiazepines should not be used for treating delirium in older patients.

“Delirium is not a homogenous entity,” Mattison said. “It has three major types: hyperactive or agitated delirium, mixed delirium and hypoactive delirium.”

Data indicate that lorazepam converts patients from a hyperactive to hypoactive delirium state, which is associated with distress, according to Mattison. Although caregivers often think the patient is more comfortable, lorazepam decreases patients’ ability to communicate and express what they are feeling.

Additional agitation was not seen in most patients receiving placebo, compared with lorazepam, indicating that lorazepam was not necessary, she said.

Mattison said antipsychotics are also often used in the hospital off-label.

“The most common indications for off-label use are delirium and agitated dementia,” Mattison said. “We know not to use them for those indications and we know not to use them for insomnia, but they are often given.”

She noted research published in the Journal of the American Geriatric Society concluded that antipsychotics given in nursing home patients are associated with a 40% to 50% increased risk for aspiration pneumonia during hospitalization.

“Hospitalists should stop giving antipsychotics for off-label uses in the hospital unless the risk-to-benefit ratio is strongly towards the benefit,” Mattison said.

“There are very limited indications for use of antipsychotics and benzodiazepines in older patients,” she said.

Transitions in care

“Transitions in care are still the holy grail in geriatric hospital medicine,” Mattison said.

She noted five critical points from the Gerontological Society of America that hospitalists should keep in mind when treating individuals living with dementia.

Hospitalists should prepare and educate patients and their caregivers around their transitions of care and ensure timely exchange of information across settings and between providers within settings, she said.

Prognosis and patient preferences can change quickly in this population, she noted. Therefore, it is important to reevaluate the preferences and goals of patients across the continuum of care, according to Mattison.

Hospitalists should also create strong interprofessional teams and use strategies to avoid unnecessary transitions in care, she said

Mobility

The majority of geriatric patients in the hospital, even if noted that they can be ambulatory, spend almost all of their time in bed, even though older patients who are more mobile have more functionality, Mattison said.

Mobility is also beneficial perioperatively and early mobilization after surgery helps with recovery, she said.

Additionally, improved mobilization decreases length of stay and the risk for venous thromboembolism, she said.

Polypharmacy

Taking five or more medications is common in older patients, but is associated with falls, mortality and an increased risk for adverse drug events, according to Mattison.

“The more medications a patient is on, the worse they do in physical and cognitive capacities,” she said.

There is a dose response with polypharmacy which reduces both cognitive and physical function, she said.

She added that there is a duration effect associated with polypharmacy.

“Any increase in medication exposure raises the risk in the individual for an adverse drug event that can lead to impaired physical and cognitive functioning,” Mattison said.

“Instead of recommending another medication maybe hospitalists should be recommending cognitive behavioral therapy,” she said, noting that it is effective.

New geriatric syndrome

“Heart failure with a preserved ejection fraction (HFpEF) is now the newest geriatric syndrome, joining falls, delirium, incontinence and frailty,” Mattison said.

“Sadly, there’s not a lot of great treatment for it aside from weight loss and exercise,” she added.

“HFpEF is a very complex phenomenon and not completely understood. It wasn’t recognized by the American Cardiology Society until 28 years ago, so it is a relatively newly defined syndrome that used to be called diastolic heart failure.”

Mattison said they are still learning more about the syndrome. – by Alaina Tedesco

Reference:

Mattison MLP. Update in geriatrics: A tale as old as time. Presented at: Hospital Medicine 2018; April 9-11; Orlando, Fla.

Disclosure: Healio Internal Medicine was unable to confirm relevant financial disclosures at the time of publication.