Just finished a long stretch of nights @BrighamMedRes, so perfect time for a #MedTwitter #Tweetorial on what I was paged for most - antipsychotics for delirium.

Executive Summary: avoid antipsychotics for delirium, and if you give them, be sure to see the patient first!!!

It's a long one, but we'll cover a lot of the basics:

1) What is delirium?

2) Do antipsychotics work for treating or preventing delirium?

3) What are the risks of antipsychotics?

4) How do we treat delirium?

What is delirium?

Well until DSM-III came about in the 1980s, there was no one diagnosis. Terms to describe delirium-like conditions ranged from ‘acute confusional state’ to ‘acute brain failure’ to my personal favorite ‘subacute befuddlement.’

3/23 https://pubmed.ncbi.nlm.nih.gov/25300023/ 
Summarizing the DSM V, the diagnosis of delirium now centers on 1) acute changes in 2) attention and 3) cognition that 4) are not explained by a pre-established or evolving neurocognitive disorder.

To diagnose delirium, you can use the "Confusion Assessment Method" or CAM.

In a systematic review, the tool has an overall sensitivity of 95% and specificity of 90% (often compared with gold standard of psychiatrist going through DSM criteria)!

5/23 https://pubmed.ncbi.nlm.nih.gov/18384586 
So we have a definition for delirium and we have a good way to diagnose it, now here comes the midnight page:

"Patient delirious - give haldol?"

But there is a reason antipsychotic memes on the internet are all of villains:

While once controversial, the data are now pretty clear that antipsychotics DO NOT prevent or treat delirium.

In the past couple years, @AnnalsofIM has published two meta-analyses on this topic. The first concludes with the resounding statement:

"Current evidence does not support routine use of...antipsychotics to treat delirium in adult inpatients."

8/23 https://pubmed.ncbi.nlm.nih.gov/31476770/ 
The second concludes:

"Current evidence does not support routine use of...antipsychotics for prevention of delirium."

(They do suggest more work is needed to comment on utility in postoperative patients specifically, but I'm an internist here).

9/23 https://pubmed.ncbi.nlm.nih.gov/31476766/ 
Ok, so antipsychotics don't reduce things like delirium incidence, delirium severity, or hospital length of stay, but do they actively do harm?

Yes. Beyond all the annoying symptoms (dry mouth and eyes, etc), they can raise risk of pneumonia, falls, and possibly death.

Second, falls.

In a study of 195,554 older adults, new prescriptions of antipsychotic medication were associated with >50% increased risk of falls and nonvertebral osteoporotic fracture.

12/23 https://pubmed.ncbi.nlm.nih.gov/25581312 
But Alex, I hear you protest, some of those studies are in outpatients.

In a study of >7000 nursing home residents who were started on antipsychotics, nearly 20% had them started during hospitalizations.

What we do inpatient has lasting effects!

14/23 https://pubmed.ncbi.nlm.nih.gov/29355891 
The first step is to realize who is at risk for delirium.

For decades studies have confirmed that dementia, certain medications (i.e. anti-cholinergics, etc), medical illnesses, age, and and male sex are associated with delirium risk.

16/23 https://pubmed.ncbi.nlm.nih.gov/9541379 
Unfortunately, even when we know who is at risk, it's hard to prevent and treat delirium. Reviews of care thoughtful bundles in the ICU and on the floor have been far from showing consistent benefits.



And, if measures to prevent delirium fail, and reorientation fails, and melatonin/other safer meds fail, and a patient with delirium is a danger to themselves or others so you're being paged for an antipsychotic at midnight.


This has been a broad overview w/ some data about the basics of delirium + antipsychotic use for the condition. There is a lot more nuance - we didn't even touch on topics like the ethical considerations of giving antipsychotics for delirium.

20/23 https://pubmed.ncbi.nlm.nih.gov/31981540 
I hope my post-nightfloat fog was useful to some. If it wasn't, I'll stick with melatonin, please.

This was written with my many IM/Geri colleagues in mind who I know are fighting to good fight against delirium including @kkidia @WalkerReddMD @Sophia_Hayes_MD @LoewenthalMd @AlexanderZheut1 @LeeLindquistMD @jesscolburn @AlexSmithMD @tony_breu and more

You can follow @AlexChaitoff.
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