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Reducing Delirium Among Patients in Palliative Care

JAMA Intern Med; 2017 Jan; Agar, Lawlor, et al

Symptoms of delirium among patients receiving palliative care were significantly greater in those treated with antipsychotics compared to those receiving placebo, a recent study found. This double-blind, parallel-arm clinical trial from August 13, 2008, to April 2, 2014, included 247 patients (mean age 74.9 years; 218 [88.3%] with cancer) with life-limiting illness, delirium, and a delirium symptoms score of 1 or more. Participants received either age-adjusted titrated doses of oral risperidone, haloperidol, or placebo solution administered every 12 hours for 72 hours, and also received supportive care. Researchers found:

  • Participants in the risperidone arm had delirium symptom scores significantly higher than those among participants in the placebo arm.
  • Similarly, for those in the haloperidol arm, delirium symptom scores were on average higher than in the placebo arm.
  • Patients in both active arms had more extrapyramidal effects compared to placebo.

Citation:

Agar MR, Lawlor PG, Quinn S, et al. Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care. A randomized clinical trial. JAMA Intern Med. 2017;177(1):34-42. doi:10.1001/jamainternmed.2016.7491.

Commentary:

Delirium is a common and challenging problem to treat in patients with dementia, older patients in the hospital, and patients receiving palliative care. Behavioral interventions are often helpful, but when patients continue to have delirium, antipsychotic agents or benzodiazepines are often used, though the data to support their use are sparse. The surprising results of this study suggest that for patients in palliative care the use of antipsychotic agents may make delirium worse rather than better. Behavioral interventions (including treatment of pain, re-orienting patients, talking in a soothing voice, and responding to concerns) is the mainstay of treatment of delirium, and further study is needed in order to define the place of medications for patients who need treatment after behavioral interventions no longer provide sufficient control of symptoms. —Neil Skolnik, MD

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