The document discusses the potential necessity and harm of using antipsychotic medications, particularly haloperidol and quetiapine, in treating delirium in elderly patients, highlighting that there is no solid evidence supporting their effectiveness. It emphasizes focusing on non-pharmacological interventions and addressing underlying causes of delirium rather than prescribing antipsychotics, which may increase risks such as mortality and delirium severity. Recommendations include behavioral interventions and reserving antipsychotics for severe cases of self-harm danger, treating for the shortest duration with minimal dosage.

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Choosing Wisely®
:
Things We Do
for No Reason™
Use of Antipsychotic Medications in Patients with
Delirium
Based on Pahwa AK, Qureshi, I, Cumbler, E. Use of Antipsychotic Medications
in Patients with Delirium. J Hosp Med. 2019;14(9):565-567.

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Clinical Scenario
• 86-year old woman with mild dementia falls and fractures hip,
requiring open reduction and internal fixation.
• On the first post-op day, she sleeps most of the day.
• Overnight she has visual hallucinations and picks at tape on her
peripheral IV, causing it to fall out twice.
• On exam she has normal vitals but is hypoactive, inattentive, and is
unable to say the day of the week or count months backward.
• Nursing requests haloperidol for delirium.

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Why You Might Think This is Necessary
• Haloperidol PPx prior to surgery reduced delirium severity
and duration (but was a small trial)1
• RCT of 42 patients on medical floor showed 55% faster
decline in DRS-R-98 in patients treated with quetiapine vs
placebo2
• 2007 Cochrane review - antipsychotics may reduce delirium
severity and duration as well as length of hospital stay in hip
surgery3
• 10-30% of patients receive antipsychotics at some point
during hospitalization, usually for delirium4,5

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Why This Is Unnecessary and Potentially Harmful
• Positive published studies actually have mixed results
• Haloperidol PPX did not actually decrease incidence of delirium on post-op
day 1.1
• RCT of quetiapine not actually powered for the primary outcome of lower
DRS-R-98 scores and there was no significant difference in severity of
delirium on days 1, 3, or 10.2
• 2016 systematic review concluded that antipsychotics did not change
length of delirium or hospitalization6
• RCT comparing haloperidol, risperidone, and placebo for delirium
treatment in palliative care and hospice patients found more severe
delirium in patients receiving antipsychotics vs placebo7
• Side effects
• Increased risk of extrapyramidal symptoms6-8
• Increased risk of aspiration pneumonia9
• Use of atypical antipsychotics in elderly patients with dementia is
associated with increased mortality10

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What You Should Do Instead
• Remove problem medications
• Treat withdrawal
• Correct metabolic disturbance
• Assess and treat infection if present
• Reduce level of invasion
• Hospital Elder Life Program nursing delirium protocol
• Focus on orientation, hydration, mobility, sensory aids, and
environment conducive to sleep
• Nonpharmacologic interventions for delirium prevention
reduce delirium incidence and prevent falls11

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Recommendations
• Address underlying modifiable contributions to delirium
paying attention to medications, pain, electrolytes, ischemia,
infection, alcohol withdrawal, and reducing invasive lines.
Deprescribe sedative/hypnotic and anticholinergic
medications.
• After addressing modifiable risk factors, attempt behavioral
interventions for continuous problematic behaviors or
symptoms of delirium.
• Reserve antipsychotics for cases where the patient poses an
immediate danger of self-harm or harm to others. Treat for the
shortest possible duration with the lowest effective dose of
antipsychotic.

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Conclusions
• No evidence supports using pharmacologic treatment for
delirium without agitation
• Some evidence to suggest harm with pharmacologic
treatment
• The patient’s peripheral IV is made less accessible and
distracting activities are offered
• The hospitalist and nurse are able to increase the patient’s
mobility and orientation and adjust the environment to be
more conducive to sleep
• Delirium resolves without pharmacologic intervention
Case Scenario

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References
1. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized
placebo-controlled study. J Am Geriatr Soc. 2005;53(10):1658-1666
2. Tahir TA, Eeles E, Karapareddy V, et al. A randomized controlled trial of quetiapine versus placebo in the treatment of delirium. J
Psychosom Res. 2010;69(5):485-490.
3. Siddiqi N, Stockdale R, Britton AM, Holmes J. Interventions for preventing delirium in hospitalized patients. Cochrane Database Syst Rev.
2007;(2):CD005563.
4. Loh KP, Ramdass S, Garb JL, Brennan MJ, Lindenauer PK, Lagu T. From hospital to community: use of antipsychotics in hospitalized
elders. J Hosp Med. 2014;9(12):802-804.
5. Herzig SJ, Rothberg MB, Guess JR, Gurwitz JH, Marcantonio ER. Antipsychotic medication utilization in nonpsychiatric hospitalizations. J
Hosp Med. 2016;11(8):543-549.
6. Neufeld KJ, Yue J, Robinson TN, Inouye SK, Needham DM. Antipsychotic medication for prevention and treatment of delirium in
hospitalized adults: a systematic review and meta-analysis. J Am Geriatr Soc. 2016;64(4):705-714.
7. 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.
8. Hatta K, Kishi Y, Wada K, et al. Antipsychotics for delirium in the general hospital setting in consecutive 2453 inpatients: a prospective
observational study. Int J Geriatr Psychiatry. 2014;29(3):253-262.
9. Herzig SJ, LaSalvia MT, Naidus E, et al. Antipsychotics and the risk of aspiration pneumonia in individuals hospitalized for nonpsychiatric
conditions: a cohort study. J Am Geriatr Soc. 2017;65(12):2580-2586
10.Jeste DV, Blazer D, Casey D, et al. ACNP White Paper: update on use of antipsychotic drugs in elderly persons with dementia.
Neuropsychopharmacology. 2008;33(5):957-970.
11. Hshieh TT, Yue J, Oh E, et al. Effectiveness of Multicomponent Nonpharmacological Delirium Interventions: A Meta-analysis. JAMA Intern
Med. 2015;175(4):512–520.

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Citation
To cite this teaching tool:

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