Antipsychotics may be ineffective for delirium, may increase severity

NATIONAL HARBOR, Md. — The data behind prescribing antipsychotics to treat patients with delirium may not be “as strong as we thought,” according to a speaker at Hospital Medicine 2019.

“Antipsychotics, despite the way we were trained, don’t actually appear to treat the pathophysiology of delirium,” Ethan Cumbler, MD, of the University of Colorado Hospital and the University of Colorado School of Medicine, said in a presentation. “If there’s a role for antipsychotics, it’s for the patient with active, dangerous psychosis due to their delirium which causes them to injure themselves or their caregivers. But for most cases of delirium, that’s not the patient we’re talking about. For most cases of delirium, antipsychotics don’t appear to treat the disease.”

Cumbler cited a meta-analysis from 2016 that found that antipsychotic use was not associated with changes in delirium duration, delirium severity or hospital or ICU length-of-stay. In addition, trial results published in The New England Journal of Medicine showed there was no difference in severity or duration of delirium between patients with ICU delirium treated with antipsychotics or placebo.

Furthermore, the 2014 guidelines from the American Geriatrics Society, which Cumbler referred to as a “huge change from where we were a decade ago,” recommend that “the prescribing practitioner should not prescribe antipsychotic medications for the treatment of older adults with postoperative delirium who are not agitated and threatening substantial harm to self or others.”

According to Cumbler, long-term antipsychotic use causes significant harm, including mortality. In addition, data published in JAMA in 2017 found that patients taking the antipsychotics haloperidol or risperidone had more severe delirium than those taking placebo. The haloperidol group also had shorter survival.

Instead of antipsychotics, Cumbler recommended melatonin as a safe and effective option to treat patients’ insomnia which, in turn, helps to mitigate delirium.

“We need something we can use to treat patients with insomnia in the hospital and most of our options have huge side effect profiles,” Cumbler said. “I’m looking for something that’s safe and might have benefit and maybe [melatonin] is it. I want to see a larger trial, but I think this is the most exciting pharmacological opportunity for the treatment of delirium in the last century.” – by Melissa J. Webb

Reference:

Cumbler E. Delirium and dementia in the inpatient setting. Presented at: Hospital Medicine 2019. March 25-27; National Harbor, Md.

Disclosures: Cumbler reports no relevant financial disclosures.