Antipsychotics for preventing and treating delirium? NOT recommended

Delirium is an acute, fluctuating change in mental status, with inattention, disorganised thinking, and altered levels of consciousness. It is a potentially life-threatening disorder characterised by high morbidity and mortality.

Its onset is often rapid and is associated with more extended hospital stays, complications and poorer outcomes. The elderly are at particular risk; they are more sensitive to changes in their baseline physiology, and delirium is easily misdiagnosed due to clinical similarities with dementia and psychosis. 

Guidelines have emphasised the importance of non-pharmacological management, but the publication of two recent systematic reviews provides essential evidence on the role of drug therapy.

Although earlier evidence suggested that antipsychotics may have a role in delirium management more recent reviews and the 2019 Cochrane review report no effect of antipsychotics in treating delirium.

However, NICE guidance, which recommends that ‘if a person with delirium is distressed or considered a risk to themselves or others, and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, consider giving short-term (usually for 1 week or less) haloperidol.

Non-pharmacological interventions that focus on mobilisaion, visual or hearing impairment, dehydration, sleep deprivation or family and friends are effective in delirium. However, in the busy environment of hospitals labour-intensive interventions may be overlooked for drug treatment. Caution should be applied when short courses are initiated; patients may end up on long-term treatment if an adequate drug review does not occur.

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