Second-generation antipsychotics may be best for delirium treatment

By Reuters Staff

NEW YORK (Reuters Health) - Second-generation antipsychotics (SGAs) may treat delirium better than placebo, usual care, or haloperidol, according to new research.

"Our results suggested that antipsychotic medications were superior to PLA/UC (placebo or usual care) in efficacy outcomes. Moreover, SGAs are more beneficial for the treatment of delirium regarding efficacy and safety outcomes compared with haloperidol," the authors wrote online September 4 in the Journal of Neurology, Neurosurgery & Psychiatry.

Dr. Taro Kishi, of the Department of Psychiatry of Fujita Health University School of Medicine in Toyoake, Aichi, Japan, and colleagues did an updated meta-analysis of antipsychotic treatments in patients with delirium.

They included randomized, placebo-controlled, or usual care (UC) controlled trials of antipsychotics in adult patients with delirium to determine the response rate.

The researchers investigated improvements in Delirium Severity Scale (DSS), Clinical Global Impression-Severity Scale (CGI-S), time to response (TTR), discontinuation rate, and individual adverse effects.

From 336 unique articles they identified and screened, they included 15 randomized controlled trials with a mean duration of 9.8 days in the final analysis. As a group, antipsychotics were superior to placebo or usual care in response rate (risk ratio = 0.22), delirium severity scale (standardized mean difference = 1.27), CGI-S (SMD = 1.57) and TTR (SMD = 1.22).

Compared with placebo/UC, the pooled antipsychotics group was associated with higher incidence of sedation (RR = 4.59) and dry mouth (RR = 13.0). Compared with haloperidol, pooled SGAs were associated with shorter TTR (SMD = 0.27) and lower extrapyramidal symptom incidence (RR = 0.31).

The researchers found no significant differences in most of the side effects, including death, between antipsychotics and placebo/UC.

"Emerging evidence suggested that close attention is required when prescribing antipsychotics in the elderly," the authors wrote. "For example, death occurred in 3.5% of patients with dementia randomized to SGAs compared with 2.3% of patients randomised to placebo, and the pooled OR for death was 1.54."

"Moreover, antipsychotic use in the elderly can raise the risk of incidences of pneumonia, stroke, and falls. Given our results confirming safety of SGAs in comparison to that of haloperidol in the treatment for patients with delirium, we suggest that the clinicians choose SGAs prior to the trial of haloperidol for the treatment of delirium. Owing to the limited number of studies included in our study, however, we were unable to explore which SGAs should be used for the treatment of delirium," they wrote.

Because the studies they examined were small, they suggested further research using larger samples.

The authors did not respond to requests for comments.

SOURCE: https://bit.ly/1OX8eD3

J Neurol Neurosurg Psychiatr 2015.