Atypical Antipsychotics versus Haloperidol for Treatment of Delirium in Acutely Ill Patients

School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA.
Pharmacotherapy (Impact Factor: 2.66). 05/2007; 27(4):588-94. DOI: 10.1592/phco.27.4.588
Source: PubMed


Delirium is common in acutely ill patients and can result in substantial morbidity if left untreated. Atypical antipsychotics have been postulated to be safer and more effective than haloperidol for treatment of this condition. To evaluate the role of atypical antipsychotics versus haloperidol for treatment of delirium in hospitalized acutely ill adults, we searched MEDLINE (1977-September 2006) and International Pharmaceutical Abstracts (1997-September 2006) for English-language publications of clinical trials that compared atypical antipsychotics and haloperidol. Four comparative studies were identified: one double-blind, randomized study (risperidone vs haloperidol), one single-blind, randomized study (olanzapine vs haloperidol), and two retrospective studies (olanzapine vs haloperidol and quetiapine vs haloperidol). These studies demonstrated that atypical antipsychotics are as efficacious as haloperidol. In addition, they appear to be associated with a lower frequency of extrapyramidal effects, and thus are safer than haloperidol. However, these conclusions are based on a limited number of studies; larger comparative trials are needed to elucidate the role of atypical antipsychotics for treating delirium in this population.

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    • "The current literature highlights the efficacy and tolerability of atypical antipsychotics in providing relief from the distressing symptoms of delirium (Lonergan et al., 2007; Rea et al., 2007). Studies have not been able to show differences in efficacy between haloperidol and aripiprazole (Boettger et al., 2011a), risperidone (Han & Kim, 2004; Kim et al., 2005; Liu et al., 2004), or olanzapine (Hu et al., 2004; Skrobik et al., 2004), and between risperidone and olanzapine (Kim et al., 2010). "
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    ABSTRACT: Objective: The aim of this study was to compare the efficacy and side-effect profile of the typical antipsychotic haloperidol with that of the atypical antipsychotics risperidone, olanzapine, and aripiprazole in the management of delirium. Method: The Memorial Delirium Assessment Scale (MDAS), the Karnofsky Performance Status (KPS) scale, and a side-effect rating were recorded at baseline (T1), after 2-3 days (T2), and after 4-7 days (T3). Some 21 cases were case-matched by age, preexisting dementia, and baseline MDAS scores, and subsequently analyzed. Results: The baseline characteristics of the medication groups were not different: The mean age of the patients ranged from 64.0 to 69.6 years, dementia was present in between 23.8 and 28.6%, and baseline MDAS scores were 19.9 (haloperidol), 18.6 (risperidone), 19.4 (olanzapine), and 18.0 (aripiprazole). The doses of medication at T3 were 5.5 mg haloperidol, 1.3 mg risperidone, 7.1 mg olanzapine, and 18.3 mg aripiprazole. Over one week, the decline in MDAS scores between medications was equal, and no differences between individual MDAS scores existed at T2 or T3. After one week, the MDAS scores were 6.8 (haloperidol), 7.1 (risperidone), 11.7 (olanzapine), and 8.3 (aripiprazole). At T2, delirium resolution occurred in 42.9-52.4% of cases and at T3 in 61.9-85.7%; no differences in assessments between medications existed. Recorded side effects were extrapyramidal symptoms (EPSs) in haloperidol- and risperidone-managed patients (19 and 4.8%, respectively) and sedation with olanzapine (28.6%). Significance of results: Haloperidol, risperidone, aripiprazole, and olanzapine were equally effective in the management of delirium; however, they differed in terms of their side-effect profile. Extrapyramidal symptoms were most frequently recorded with haloperidol, and sedation occurred most frequently with olanzapine.
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    • "Second-generation antipsychotics, commonly known as atypical antipsychotics, include risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel). They are equally effective in treating delirium and have fewer side effects than haloperidol [89,90]. Atypical antipsychotics may reduce the duration of delirium in the ICU according to the 2013 SCCM PAD guidelines [30]. "
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    ABSTRACT: Delirium is a serious complication that commonly occurs in critically ill patients in the intensive care unit (ICU). Delirium is frequently unrecognized or missed despite its high incidence and prevalence, and leads to poor clinical outcomes and an increased cost by increasing morbidity, mortality, and hospital and ICU length of stay. Although its pathophysiology is poorly understood, numerous risk factors for delirium have been suggested. To improve clinical outcomes, it is crucial to perform preventive measures against delirium, to detect delirium early using valid and reliable screening tools, and to treat the underlying causes or hazard symptoms of delirium in a timely manner.
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    • "Although the cholinesterase inhibitors (eg, donepezil, rivastigmine, galantamine, and physostigmine) are, in principle, useful for patients whose delirium-related behavioral disturbances are predicated on cholinergic deficit, the evidence supporting their use for this purpose is limited [140]. Atypical antipsychotics seem as effective as haloperidol for the treatment of delirium in patients who are critically ill (including those who are mechanically ventilated), tend not to interfere strongly with cerebral dopaminergic function, and produce fewer adverse motor effects than haloperidol [141]. These agents also may facilitate, or at least not adversely affect, cognition when used for the treatment of posttraumatic delirium, although there currently are limited data with which to support this suggestion [142] [143]. "
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    ABSTRACT: Traumatic brain injury (TBI) results in approximately 230,000 hospitalizations annually in the United States. Advances in the acute management of TBI have improved survival after TBI. Many TBI survivors develop neurobehavioral disturbances in the acute post-injury period. Neurobehavioral sequelae present clinical management challenges for critical care professionals. This article defines and describes TBI and reviews its common neuroanatomic and neurobehavioral consequences. These disturbances are organized under the framework of posttraumatic encephalopathy, and the characteristic forms and stages of recovery of this condition are discussed. Recommendations regarding evaluation and management of posttraumatic neurobehavioral problems in the critical care setting are offered.
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