Things We Do For No Reason: Use of Antipsychotic Medications in Patients with Delirium

Inspired by the ABIM Foundation’s Choosing Wisely^® campaign, the “Things We Do for No Reason^TM” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR^TM series do not represent “black and white” conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

An 86-year-old woman with mild dementia falls at home while preparing a meal. Her son brings her to the emergency department for excruciating pain in her right hip. X-rays reveal a fractured right femur that requires open reduction and internal fixation. On the first postoperative day, she does not participate in therapy and sleeps most of the day. Overnight, a nurse observes her calmly speaking to a hallucination of a family member in the room and picking at the tape around her peripheral intravenous catheter (PIV) causing the PIV to fall out twice. Her vital signs are temperature 36.7°C, pulse 82 beats per minute, respirations 12 breaths per minute, blood pressure 143/72 mm Hg, and pulse oximetry of 99% on room air. She is hypoactive, distractedly picks at her clothing and PIV, inattentive, and unable to say the day of the week or count months backward. Nursing asks for haloperidol for her delirium.

Delirium is an acute change in cognition characterized by inattention typically associated with disorganized thinking and/or alteration in consciousness.¹ Delirium occurs in almost 25% of hospitalized patients, and clinicians have a limited pharmacologic armamentarium to treat it, given the absence of benefit for acetylcholinesterase inhibitors and concern that benzodiazepine medications cause/exacerbate delirium.^2-4 Another treatment option is antipsychotic medications which block dopamine since dopamine excess is a key element in the neurotransmitter pathophysiology of delirium.⁵ A small 2005 trial of haloperidol prophylaxis in hip fracture patients found that haloperidol reduced the overall severity and duration of delirium.⁶ Based in part on this trial, a 2007 Cochrane Systematic Review concluded that antipsychotics “may reduce severity and duration of delirium episodes and shorten length of hospital stay in hip surgery.”⁷ Another study in 2010 demonstrated a 55% faster decline in total Delirium Rating Scale-Revised 98 (DRS-R-98) scores in patients on a general/medical-surgical floor receiving quetiapine treatment compared to those who received placebo.⁸

Studies show that 10%-30% of patients receive antipsychotics at some point during their hospitalization, usually for delirium.^9,10 Variability in antipsychotic prescribing patterns not explained by patient characteristics suggests the local culture may influence antipsychotic prescribing practices when evidence from randomized controlled trials is sparse or conflicting.¹⁰